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Background: Delayed gastric emptying (DGE) is a common complication after esophagectomy. BOTOX injections and pyloric surgeries (PS), including pyloroplasty (PP) and pyloromyotomy (PM), are performed intraoperatively as prophylaxis against DGE. This study compares the effects of pyloric BOTOX injection and PS for preventing DGE post-esophagectomy. Methods: We retrospectively reviewed Moffitt's IRB-approved database of 1364 esophagectomies, identifying 475 patients receiving BOTOX or PS during esophageal resection. PS was further divided into PP and PM. Demographics, clinical characteristics, and postoperative outcomes were compared using Chi-Square, Fisher's exact test, Wilcoxon rank-sum, and ANOVA. Propensity-score matching was performed between BOTOX and PP cohorts. Results: 238 patients received BOTOX, 108 received PP, and 129 received PM. Most BOTOX patients underwent fully minimally invasive robotic Ivor-Lewis esophagectomy (81.1% vs 1.7%) while most PS patients underwent hybrid open/Robotic Ivor-Lewis esophagectomy (95.7% vs 13.0%). Anastomotic leak (p = 0.57) and pneumonia (p = 0.75) were comparable between groups. However, PS experienced lower DGE rates (15.9% vs 9.3%; p = 0.04) while BOTOX patients had less postoperative weight loss (9.7 vs 11.45 kg; p = 0.02). After separating PP from PM, leak (p = 0.72) and pneumonia (p = 0.07) rates remained similar. However, PP patients had the lowest DGE incidence (1.9% vs 15.7% vs 15.9%; p = < 0.001) and the highest bile reflux rates (2.8% vs 0% vs 0.4%; p = 0.04). Between matched cohorts of 91 patients, PP had lower DGE rates (18.7% vs 1.1%; p = < 0.001) and less weight loss (9.8 vs 11.4 kg; p = < 0.001). Other complications were comparable (all p > 0.05). BOTOX was consistently associated with shorter LOS compared to PS (all p = < 0.001). Conclusion: PP demonstrates lower rates of DGE in unmatched and matched analyses. Compared to BOTOX, PS is linked to reduced DGE rates. While BOTOX is associated with more favorable LOS, this may be attributable to difference in operative approach. PP improves DGE rates after esophagectomy without improving other postoperative complications. [ABSTRACT FROM AUTHOR]

Background/Aims: During esophagectomy for malignancy, the anterior and posterior branches of the vagus nerve are transected in order to achieve surgical radicality. This leads to loss of central nervous system-control of the pylorus which may lead to delayed gastric emptying. We aimed to investigate the feasibility of the EndoFLIP technique for assessment of pyloric biomechanical properties in patients undergoing esophagectomy. Methods: A feasibility study in six patients undergoing surgery was conducted. EndoFLIP measurements were carried out preoperative (Pre-op), after surgical resection (Post-op) and following prophylactic balloon dilatation of the pylorus (Post-dil). By measuring the cross-sectional area and pressure of the pylorus the pyloric compliance and the incremental pressure-strain elastic modulus (Ep) were calculated. Results: Placing the catheter in the pyloric region was successfully achieved in all six patients. No complications were observed. Resection of the esophagus increased the incremental pyloric elastic modulus (Ep) from 0.59 ± 0.18 kPa to 0.99 ± 0.34 kPa (p = 0.03). After dilatation, the Ep was reduced to 0.53 ± 0.23 kPa (p = 0.04), which was close to Pre-op (p = 0.62). The pyloric compliance showed a similar pattern as that found for Ep. Conclusion: The EndoFLIP system holds promise for assessment of biomechanics of the pyloric region in patients undergoing esophagectomy for cancer. [ABSTRACT FROM AUTHOR]

Background: Current research on delayed gastric emptying (DGE) after pancreatic surgery is predominantly focused on pancreaticoduodenectomy (PD), with little exploration into DGE following total pancreatectomy (TP). This study aims to investigate the risk factors for DGE after TP and develop a predictive model. Methods: This retrospective cohort study included 106 consecutive cases of TP performed between January 2013 and December 2023 at Peking Union Medical College Hospital (PUMCH). After applying the inclusion criteria, 96 cases were selected for analysis. These patients were randomly divided into a training set (n = 67) and a validation set (n = 29) in a 7:3 ratio. LASSO regression and multivariate logistic regression analyses were used to identify factors associated with clinically relevant DGE (grades B/C) and to construct a predictive nomogram. The ROC curve, calibration curve, decision curve analysis (DCA), and clinical impact curve (CIC) were employed to evaluate the model's prediction accuracy. Results: The predictive model identified end-to-side gastrointestinal anastomosis, intraoperative blood transfusion, and venous reconstruction as risk factors for clinically relevant DGE after TP. The ROC was 0.853 (95%CI 0.681–0.900) in the training set and 0.789 (95%CI 0.727–0.857) in the validation set. The calibration curve, DCA, and CIC confirmed the accuracy and practicality of the nomogram. Conclusion: We developed a novel predictive model that accurately identifies potential risk factors associated with clinically relevant DGE in patients undergoing TP. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is one of the most common reasons for morbidity after pancreatoduodenectomy. The technical characteristics of anastomosis that could be affected by surgeon may offer a relevant chance to improve postoperative DGE rates. We investigated the effect of a technical modification of gastrojejunostomy after the classical pancreaticoduodenectomy on DGE. Materials and methods: A total of 161 patients underwent classical pancreaticoduodenectomy (with 20–40 percent antrectomy) due to pancreatic adenocarcinoma at the Department of General Surgery, Marmara University, School of Medicine Hospital, from February 2019 to May 2023, and those who met the inclusion criteria were enrolled. One hundred twenty patients had undergone classical end-to-side gastrojejunostomy (Classical GJ group), and 41 had undergone Marmara-Yegen cutting side-to-side gastrojejunostomy (M-Yc group). DGE was defined according to the International Working Group on Pancreatic Surgery, and postoperative DGE rates of both groups were compared. In addition, multivariate analysis was performed to identify possible independent predictive factors for DGE. Results: The total incidence of DGE was 31% in the Classical GJ group and 17% in the (M-Yc group). Although there was no significant difference between the groups regarding DGE and DGE grades (p = 0.1), DGE was distinctly lower in the M-Yc GJ group. In multi-variant analysis, Clavien-Dindo grade 3a and above postoperative complication was determined as independent predictors for DGE. Conclusions: We tried to explain the mechanism of DGE in terms of anatomical configuration. The incidence and severity of DGE decreased in patients who underwent M-Yc GJ. [ABSTRACT FROM AUTHOR]

Simple Summary: Immune checkpoint inhibitors (ICIs) offer improved outcomes for patients with various malignancies but they have also been associated with immune-related adverse events. Gastroparesis, a gastrointestinal (GI) motility disorder characterized by delayed gastric emptying (GE) and upper GI symptoms, has been linked to ICIs through histological studies indicating myenteric plexopathy. The aim of our retrospective study was to evaluate the prevalence, clinical course, and treatment for both patients with pre-existing gastroparesis and those with new symptoms of delayed GE after ICI. We found 39 patients with new delayed GE post-ICI (prevalence of 0.2%) and 37 with pre-existing gastroparesis, of which only 4 (11%) had a flare of symptoms post-ICI. We found that delayed GE post-ICI therapy is rare but with late onset and prolonged duration. The presence of alternative etiology of gastroparesis did not affect patients' duration of delayed GE symptoms or overall survival. Immune checkpoint inhibitors (ICIs) can cause myenteric plexopathy, which could result in delayed gastric emptying (GE) and possibly gastroparesis. We assessed the clinical outcomes of patients who had pre-existing gastroparesis or who developed symptoms of delayed GE following ICI therapy. We retrospectively identified adults with ICD-9 and ICD-10 codes for gastroparesis who received ICI therapy between 1 January 2020 and 31 December 2022 at a tertiary cancer center. Of 76 eligible patients, 37 had pre-existing gastroparesis; 39 (0.2% of the more than 18,000 screened) developed symptoms of delayed GE after ICI therapy, of which 27 (69%) patients had an alternative etiology for delayed GE. Four patients (11%) with pre-existing gastroparesis had a flare-up after ICI, and the median time to flare-up was 10.2 months (IQR, 0.7–28.6 months); for patients with new onset of suspected delayed GE after ICI, the median time to symptom onset was 12.8 months (IQR, 4.4–35.5 months). The clinical symptom duration of patients without an alternative etiology (74.5 days (IQR, 21.5–690 days)) and those with an alternative etiology (290 days (IQR, 147–387 days)) did not differ significantly (p = 1.00). Delayed GE after ICI therapy is a rare presentation but has a late onset and a prolonged symptom duration. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is a frequent complication after pancreatoduodenectomy. Preoperative factors are limited and controversial. This study aims to identify associated factors related to this complication in the Colombian population. Methods: A retrospective review of a prospectively collected database was conducted. All patients over 18 years of age who underwent pancreaticoduodenectomy were included. Associations with DGE syndrome were evaluated with logistic regression analysis, Odds ratio, and b-coefficient were provided when appropriate. Results: 205 patients were included. Male patients constituted 54.15% (n = 111). 53 patients (25.85%) were diagnosed with DGE syndrome. Smoking habit (OR 17.58 p 0.00 95% CI 7.62–40.51), hydromorphone use > 0.6 mg/daily (OR 11.04 p 0.03 95% CI 1.26–96.66), bilirubin levels > 6 mg/dL (OR 2.51 p 0.02 95% CI 1.12–5.61), and pancreatic fistula type B (OR 2.72 p 0.02 CI 1.74–10.00). Discussion: Smoking history, opioid use (hydromorphone > 0.6 mg/Daily), type B pancreatic fistula, and bilirubin levels > 6 mg/dL should be considered as risk factors for DGE. [ABSTRACT FROM AUTHOR]

Background: Gastro-esophageal reflux (GORD) following sleeve gastrectomy (SG) is a central challenge, and precise indications for revisional surgery or the physiology have not been precisely defined. We aimed to determine whether OAGB performed for reflux post-SG (1) accelerates gastric emptying half-time, (2) reduces the frequency and severity of reflux events, and (3) improves reflux symptoms. Methods: We undertook a prospective trial (ACTRN12616001089426). There were 22 participants who underwent measurement before and after revisional surgery with 29 optimal SG (patients with optimal outcome from their primary surgery) as controls. All participants underwent a protocolized nuclear scintigraphy, 24-h pH monitoring, and gastroscopy and completed objective questionnaires. Results: Trial patients were 90.9% female, age 44.4 years. Conversion from SG to OAGB was at a median of 45.2 ± 19.6 months. Scintigraphy showed an increased rate of gastric emptying post-OAGB 34 (IQR 14) vs 24 (IQR 10.3) min, p-value 0.008, with decreased number of reflux events post-prandially (39 (IQR 13) vs 26 (IQR 7), p-value 0.001). This data correlated with the pH analysis; total acid events substantially reduced post-OAGB 58.5 (IQR 88) vs 12 (IQR 9.4) events, p-value 0.017. Endoscopic findings indicated a reduction in incidence of bile stasis 72.7% vs 40.9% post-OAGB, p-value < 0.00010. Post-OAGB, patients experienced less frequent regurgitation (12 ± 4.1 vs. 5.5 ± 3, p-value 0.012) and reflux (37.1 ± 15.7 vs. 16.8 ± 12.6, p-value 0.003). Conclusions: We found OAGB is an effective treatment for reflux associated with delayed gastric emptying post-SG. The likely mechanisms is by, an increase in the rate of gastric clearance and reduced reflux events and overall esophageal acid exposure. This suggests that some forms of post-SG reflux are driven by slower emptying of the residual stomach and are amenable to treatment with drainage above the incisura. [ABSTRACT FROM AUTHOR]

Inflammatory bowel disease (IBD) is a clinical condition of the gastrointestinal tract that has significant incidence in childhood. Major symptoms include abdominal pain, dyspepsia, delayed gastric emptying, anorexia, diarrhea and weight loss. IBD etiopathogenesis is multifactorial, with a proven involvement of cytokines. In this regard, cytokines like resistin and adiponectin produced by adipose tissue play a crucial role in inflammation. Particularly, resistin seems related to IBD severity and is considered a promising marker of disease occurrence and progression. Unraveling its mechanism of action and downstream effectors is mandatory when designing novel therapies. This preclinical study aims to further elucidate the action of resistin in causing functional gastrointestinal alterations, comparing it with the well-defined effect of adiponectin. To this end, we carried out electrophysiological analysis on murine gastric fundus. We found that resistin, similarly to adiponectin, increases smooth muscle cell (SMC) capacitance, indicative of cell surface remodeling, which is consistent with relaxation. However, contrary to adiponectin, resistin unalters membrane potential and inward Ca2+ entry and scarcely affects outward current, suggesting its inefficacy in markedly modifying electrical phenomena on the SMC membrane. This outcome, supporting the role of resistin in gastrointestinal distention, as observed in IBD, rules out a strikingly direct effect on SMCs. [ABSTRACT FROM AUTHOR]

Purpose: Quality of life (QoL) is temporarily compromised after pancreatic surgery, but no evidence for a negative impact of postoperative complications on QoL has been provided thus far. Delayed gastric emptying (DGE) is one of the most common complications after pancreatic surgery and is associated with a high level of distress. Therefore, the aim of this study was to analyse the influence of DGE on QoL. Methods: This single-centre retrospective study analysed QoL after partial duodenopancreatectomy (PD) via the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30). The QoL of patients with and without postoperative DGE was compared. Results: Between 2010 and 2022, 251 patients were included, 85 of whom developed DGE (34%). Within the first postoperative year, compared to patients without DGE, those with DGE had a significantly reduced QoL, by 9.0 points (95% CI: -13.0 to -5.1, p < 0.001). Specifically, physical and psychosocial functioning (p = 0.020) decreased significantly, and patients with DGE suffered significantly more from fatigue (p = 0.010) and appetite loss (p = 0.017) than patients without DGE. After the first postoperative year, there were no significant differences in QoL or symptom scores between patients with DGE and those without DGE. Conclusion: Patients who developed DGE reported a significantly reduced QoL and reduced physical and psychosocial functioning within the first year after partial pancreatoduodenectomy compared to patients without DGE. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) commonly occurs after pancreaticoduodenectomy (PD). Risk factors for DGE have been reported in open PD but are rarely reported in laparoscopic PD (LPD). This study was designed to evaluate the perioperative risk factors for DGE and secondary DGE after LPD in a single center. Methods: This retrospective cohort study included patients who underwent LPD between October 2014 and April 2023. Demographic data, preoperative, intraoperative, and postoperative data were collected. The risk factors for DGE and secondary DGE were analyzed. Results: A total of 827 consecutive patients underwent LPD. One hundred and forty-two patients (17.2%) developed DGE of any type. Sixty-five patients (7.9%) had type A, 62 (7.5%) had type B, and the remaining 15 (1.8%) had type C DGE. Preoperative biliary drainage (p = 0.032), blood loss (p = 0.014), and 90-day any major complication with Dindo-Clavien score ≥ III (p < 0.001) were independent significant risk factors for DGE. Seventy-six (53.5%) patients were diagnosed with primary DGE, whereas 66 (46.5%) patients had DGE secondary to concomitant complications. Higher body mass index, soft pancreatic texture, and perioperative transfusion were independent risk factors for secondary DGE. Hospital stay and drainage tube removal time were significantly longer in the DGE and secondary DGE groups. Conclusion: Identifying patients at an increased risk of DGE and secondary DGE can be used to intervene earlier, avoid potential risk factors, and make more informed clinical decisions to shorten the duration of perioperative management. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to investigate the utility of gastrostomy tube (G-tube) placement in reducing delayed gastric emptying (DGE) among patients undergoing pancreaticoduodenectomy (PD). Methods: We retrospectively reviewed consecutive patients undergoing PD from 2015 to 2020 at our institution. Thirty-day patient outcomes including DGE, length of stay (LOS), reoperation rates, and morbidity were analyzed in patients with or without G-tube placement. Results: 128 patients with resectable pancreatic head cancer (54 females, median age 68.50 [59.00–74.00]) underwent PD (66 had G-tube placement and 62 did not). There was no significant difference in the incidence of DGE (n = 17 vs. n = 17, p = 0.612), and LOS between the groups. Postoperative ileus (p = 0.007) was significantly lower while atrial fibrillation (p = 0.037) was higher among the G-tube group. Gastrostomy-related complications (p = 0.001) developed in ten patients: skin-related complications (n = 6), tube dislodgement (n = 3) and clogging (n = 1). Nine patients required reoperation during index admission (n = 4 vs. n = 5, p = 1.000). There was no difference in 30-day readmissions (n = 7 vs. n = 5, p = 0.471) and no difference in 30 or 90-day mortality. Conclusion: Gastrostomy tube placement during index PD did not affect the incidence of DGE. However, patients experienced significant morbidities due to G-tube-related complications. Placement of gastrostomy tubes at the index PD offers no clinical benefits. [ABSTRACT FROM AUTHOR]

Gastrointestinal motility disorders tend to develop after pancreaticoduodenectomy (PD). The objectives of this study were: (1) to investigate the impact of needleless transcutaneous neuromodulation (TN) on the postoperative recuperation following pancreaticoduodenectomy (PD), and (2) to explore the underlying mechanisms by which TN facilitates the recovery of gastrointestinal function after PD. A total of 41 patients scheduled for PD were randomized into two groups: the TN group (n = 21) and the Sham-TN group (n = 20). TN was performed at acupoints ST-36 and PC-6 twice daily for 1 h from the postoperative day 1 (POD1) to day 7. Sham-TN was performed at non-acupoints. Subsequent assessments incorporated both heart rate variation and dynamic electrogastrography to quantify alterations in vagal activity (HF) and gastric pacing activity. 1)TN significantly decreased the duration of the first passage of flatus (p < 0.001) and defecation (p < 0.01) as well as the time required to resume diet (p < 0.001) when compared to sham-TN;2)Compared with sham-TN, TN increased the proportion of regular gastric pacing activity (p < 0.01);3) From POD1 to POD7, there was a discernible augmentation in HF induced by TN stimulation(p < 0.01);4) TN significantly decreased serum IL-6 levels from POD1 to POD7 (p < 0.001);5) TN was an independent predictor of shortened hospital stay(β = − 0.349, p = 0.035). Needleless TN accelerates the recovery of gastrointestinal function and reduces the risk of delayed gastric emptying in patients after PD by enhancing vagal activity and controlling the inflammatory response. [ABSTRACT FROM AUTHOR]

Esophagectomy is a technically complex operation performed for both benign and malignant esophageal disease. Medical and surgical advancements have led to improved outcomes in esophagectomy patients over the past several decades; however, surgeons must remain vigilant as complications happen often and can be severe. Post-esophagectomy complications can be grouped into early and late categories. The aim of this review is to discuss the early complications of esophagectomy along with their risk factors, work-up, and management strategies with special attention given to anastomotic leaks. [ABSTRACT FROM AUTHOR]

Objectives: Delayed gastric emptying create a risk of pulmonary aspiration during anesthesia. We aim to assess the antral cross-sectional area (CSA) and gastric volume using ultrasound techniques and to investigate the relationship between these variables and both the duration and regulation of type 2 diabetes mellitus (DM). Methods: Gastric volume was estimated by measuring the antral CSA in the supine and right lateral decubitus (RLD) positions in 80 patients. The antral content was qualitatively classified according to Perlas et al. (grades 0, 1, and 2), and gastric volume was computed using a previously described formula. The presence of solid content or > 1.5 mL/kg fluid in the stomach was classified as indicative of a full stomach. Results: The mean duration of diabetes among the subjects was 9.4 ± 3.7 years. The mean fasting duration was 10.2 ± 2.1 hours for solids and 2.5 ± 0.7 for liquids. Twelve of the 80 patients exhibited grade 2 stomach. Age (p = 0.005), Body mass index (p = 0.001), solid fasting duration (p = 0.027), and supine and RLD CSA (p < 0.001 for both) were significantly associated with full stomach. A history of ≥ 8 years of diabetes (p < 0.001) and peripheral neuropathy (p = 0.005) was identified as a risk factor for a full stomach. Conclusions: Despite adherence to standard fasting protocols, 15% of the type 2 DM patients were identified with a 'full stomach' condition. Preoperative ultrasound assessment of gastric contents in patients with type 2 DM, especially with long-standing diabetes (≥ 8 years) and with peripheral neuropathy is recommended. The findings of this study necessitate additional investigation to support the conceptualization of specific guidelines for diabetes to mitigate the risk of pulmonary aspiration. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) remains one of the major complications after pancreaticoduodenectomy (PD), with discrepant reports of its contributing factors. This study aimed to develop a nomogram to identify potential predictors and predict the probability of DGE after PD. Methods: This retrospective study enrolled 422 consecutive patients who underwent PD from January 2019 to December 2021 at our institution. The LASSO algorithm and multivariate logistic regression were performed to identify independent risk and protective factors associated with clinically relevant delayed gastric emptying (CR-DGE). A nomogram was established based on the selected variables. Then, the calibration curve, ROC curve, decision curve analysis (DCA), and clinical impact curve (CIC) were applied to evaluate the predictive performance of our model. Finally, an independent cohort of 45 consecutive patients from January 2022 to March 2022 was enrolled to further validate the nomogram. Results: Among 422 patients, CR-DGE occurred in 94 patients (22.2%). A previous history of chronic gastropathy, intraoperative plasma transfusion ≥ 400 ml, end-to-side gastrointestinal anastomosis, intra-abdominal infection, incisional infection, and clinically relevant postoperative pancreatic fistula (CR-POPF) were identified as risk predictors. Minimally invasive pancreaticoduodenectomy (MIPD) was demonstrated to be a protective predictor of CR-DGE. The areas under the curve (AUCs) were 0.768 (95% CI, 0.706–0.830) in the development cohort, 0.766 (95% CI, 0.671–0.861) in the validation cohort, and 0.787 (95% CI, 0.633–0.940) in the independent cohort. Then, we built a simplified scale based on our nomogram for risk stratification. Conclusions: Our study identified seven predictors and constructed a validated nomogram that effectively predicted CR-DGE for patients who underwent PD. [ABSTRACT FROM AUTHOR]

Four adult horses with histories of moderate abdominal pain and inappetence were diagnosed with delayed gastric emptying and gastric impaction attributed to pyloroduodenal obstruction (three cases) or duodenitis (one case). A stapled side‐to‐side gastrojejunostomy was performed on all horses. Two horses returned to work and survived ≥3 years. One horse was euthanased 6 months post‐surgery due to recurrent abdominal pain, and one was found dead 5 months postsurgery after an unattended foaling. [ABSTRACT FROM AUTHOR]

Diabetic gastroparesis carries a heavy burden on people with diabetes and the healthcare system. It remains underdiagnosed and represents challenges to treat. This article reviews the epidemiology, pathophysiology, clinical features, diagnosis and treatment of diabetic gastroparesis. The disorder is characterized by delayed gastric emptying without evidence of mechanical gastric outflow obstruction. It presents with upper gastrointestinal (GI) symptoms such as nausea, vomiting, early satiety, postprandial fullness, upper abdominal discomfort and or bloating. As the prevalence of diabetes has been growing over the last few decades, we would expect an increased incidence of delayed gastric emptying in poorly controlled diabetes and perhaps in line with the increasing use of medications that act on the GI tract such as incretin-based therapy. The disease results from multiple reversible and irreversible mechanisms. Diagnosing diabetic gastroparesis requires careful history, examination and investigations to exclude other disorders that could mimic its clinical presentation. Treatment involves a wide variety of options starting with optimization of glycaemic control, stopping any offending medications and lifestyle modifications followed by the introduction of medical therapeutics such as prokinetics. Then, surgical interventions are considered in refractory cases. [ABSTRACT FROM AUTHOR]

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Levodopa is the gold standard for the symptomatic treatment of Parkinson's disease (PD). There are well documented motor and non‐motor fluctuations, however, that occur almost inevitably once levodopa is started after a variable period in people with PD. Whilst brain neurodegenerative processes play a part in the pathogenesis of these fluctuations, a range of barriers across the gastrointestinal (GI) tract can alter levodopa pharmacokinetics, ultimately contributing to non‐optimal levodopa response and symptoms fluctuations. GI barriers to levodopa transport and absorption include dysphagia, delayed gastric emptying, constipation, Helicobacter pylori infection, small intestinal bacterial overgrowth and gut dysbiosis. In addition, a protein‐rich diet and concomitant medication intake can further alter levodopa pharmacokinetics. This can result in unpredictable or sub‐optimal levodopa response, 'delayed on' or 'no on' phenomena. In this narrative review, we provided an overview on the plethora of GI obstacles to levodopa transport and absorption in PD and their implications on levodopa pharmacokinetics and development of motor fluctuations. In addition, management strategies to address GI dysfunction in PD are highlighted, including use of non‐oral therapies to bypass the GI tract. [ABSTRACT FROM AUTHOR]

Delayed gastric emptying (DGE) is common in patients undergoing pancreaticoduodenectomy (PD). The effect of DGE on mortality is less clear. We sought to identify predictors of mortality in patients undergoing PD for pancreatic adenocarcinoma hypothesizing DGE to independently increase risk of 30-day mortality. The ACS-NSQIP targeted pancreatectomy database (2014–2017) was queried for patients with pancreatic adenocarcinoma undergoing PD. A multivariable logistic regression analysis was performed. Separate sensitivity analyses were performed adjusting for postoperative pancreatic fistula (POPF) grades A–C. Out of 8011 patients undergoing PD, 1246 had DGE (15.6%). About 8.5% of patients with DGE had no oral intake by postoperative day-14. The DGE group had a longer median operative duration (373 vs. 362 min, p = 0.019), and a longer hospital length of stay (16.5 vs. 8 days, p < 0.001). After adjusting for age, gender, comorbidities, preoperative chemotherapy, preoperative radiation, open versus laparoscopic approach, vascular resection, deep surgical space infection (DSSI), postoperative percutaneous drain placement, and development of a POPF, DGE was associated with an increased risk for 30-day mortality (OR 3.25, 2.16–4.88, p < 0.001). On sub-analysis, grades A and B POPF were not associated with risk of mortality while grade C POPF was associated with increased risk of mortality (OR 5.64, 2.24–14.17, p < 0.001). The rate of DGE in patients undergoing PD in this large database was over 15%. DGE is associated with greater than three times the increased associated risk of mortality, even when controlling for POPF, DSSI, and other known predictors of mortality. [ABSTRACT FROM AUTHOR]

Introduction: We investigated the effect of the gastrojejunostomy position on the postoperative oral intake in patients who have undergone pancreaticoduodenectomy (PD). Methods: We investigated 119 patients who underwent PD between June 2013 and December 2019 and examined the effect of the horizontal and vertical distance rates of the gastrojejunostomy position on the postoperative oral intake. The patients were categorized as having poor or good oral intake based on whether their intake was up to half the required calorie intake. Results: There were significant differences in the number of cases with grade B or C postoperative pancreatic fistula (good, 20.3% vs. poor, 60.0%; p < 0.001), horizontal distance rate (good, 0.57 vs. poor, 0.48; p = 0.02), and postoperative hospitalization period (good, 15 vs. poor, 35 days; p < 0.001). However, there was no significant difference in the vertical distance rate (good, 0.67 vs. poor, 0.71; p = 0.22). The horizontal distance rate was the independent risk factor for postoperative poor oral intake at 2–3 weeks (risk ratio, 3.69; 95% CI: 1.48–9.20). Discussion: The oral intake was greater in patients whose gastrojejunostomy position in PD was farther from the median, suggesting the necessity of intraoperative placement of the gastrojejunostomy position as far from the median as possible. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is a major complication of pancreatoduodenectomy (PD). Several efforts have been made to decrease the incidence of DGE. However, the optimal anastomotic method for gastro/duodenojejunostomy (GJ) remains debatable. Moreover, few studies have reported the impact of GJ surgical techniques on outcomes following robotic pancreatoduodenectomy (RPD). This study aimed to investigate the surgical outcomes of robot-sewn and stapled GJ anastomoses in RPD. Methods: Forty patients who underwent RPD at the Okayama University Hospital between September 2020 and October 2022 were included. The outcomes between robot-sewn and stapled anastomoses were compared. Results: The mean [standard deviation (SD)] operative and GJ time were 428 (63.5) and 34.0 (15.0) minutes, respectively. Postoperative outcomes included an overall incidence of DGE of 15.0%, and the mean postoperative hospital stays were 11.6 (5.3) days in length. The stapled group (n = 21) had significantly shorter GJ time than the robot-sewn group (n = 19) (22.7 min versus 46.5 min, p < 0.001). Moreover, stapled GJ cases were significantly associated with a lower incidence of DGE (0% versus 21%, p = 0.01). Although not significant, the stapled group tended to have shorter postoperative hospital stays (9.9 days versus 13.5 days, p = 0.08). Conclusions: Our findings suggest that stapled GJ anastomosis might decrease anastomotic GJ time and incidence of DGE after RPD. Surgeons should select a suitable method for GJ anastomosis based on their experiences with RPD. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to investigate the incidence of delayed gastric emptying among the patients receiving laparoscopic distal gastrectomy, and to explore their clinical features and risk factors. Methods: Clinical data were collected for 223 patients who underwent laparoscopic distal gastrectomy for gastric cancer. We retrospectively evaluated the clinicopathological features and analyzed the incidence of delayed gastric emptying among 223 patients. Delayed gastric emptying was diagnosed by patient's symptoms and the plane radiograph with an air fluid level and dilation of the remnant stomach. Results: Delayed gastric emptying was found in five (2.2%) of the 223 patients. By univariate logistic regression analysis, greater American Society of Anesthesiologists Physical Status (ASA‐PS) and older age were significantly related to occurrence of delayed gastric emptying. By multivariate logistic regression analysis, older age was independently significantly related to incident delayed gastric emptying. The area under the curve (AUC) ((95% CI) of the receiver operating characteristic (ROC) was 0.842 (0.561–0.957). The best cutoff for discriminating patients with and without delayed gastric emptying was 80 years (sensitivity 80% and specificity 83%). Conclusion: Our study found the occurrence of delayed gastric emptying is possibly correlated with age. Therefore, careful perioperative observation in elderly patients may possibly be important for possible development of delayed gastric emptying after laparoscopic distal gastrectomy. [ABSTRACT FROM AUTHOR]

Background: To evaluate whether insertion of self-biodegradable stent into the pylorus to prevent delayed-gastric emptying after pylorus-preserving gastrectomy is feasible and safe through porcine experiment. Methods: Self-biodegradable dumbbell-shaped pyloric stents were designed from absorbable suture materials: poly(glycolide-co-caprolactone) (PGCL) or poly-p-dioxanone (PPDO). After gastrotomy on ten pigs, each stent was inserted: two shams, four PGCL stents, and four PPDO stents. Body weight (Bwt), body temperature (BT), complete blood cell (CBC) count, and plain X-ray were evaluated. On postoperative day (POD) 13, euthanasia was performed for histologic evaluation. Results: Operation was successfully performed in all ten pigs. Without tagging suture, both stents migrated before POD 3. The migration was delayed up to POD 13, when the tagging sutures (-t) were applied between stent and stomach wall. Self-degradation of PGCL started from POD 3, and stents were completely excreted from the abdomen by POD 8. Although PPDO were also weakened as self-degradation progressed, its shape was maintained in gastrointestinal tract for 13 days. Unexpected sudden death occurred in the pig with PPDO-t2 on POD 10, which is more likely due to acute volvulus rather than stent-related complication. There was no significant difference between three groups in terms of Bwt, BT, CBC, and histology (sham vs. PGCL vs. PPDO, all p > 0.05). Conclusion: The concept of biodegradable stents made of absorbent suture material seems feasible in porcine experiment. Among them, PGCL which has shown rapid absorption, appears to be a more suitable material for transient pyloric absorbable stent when considering safety aspect. [ABSTRACT FROM AUTHOR]

Simple Summary: Delayed gastric emptying is a disorder in which the stomach doesn't empty food and fluids as fast as it normally should. This condition is common following the removal of the esophagus for treatment of esophageal cancer. One option for the treatment of this motility disorder include the injection of botulinum toxin into the muscular ring at the opening of the stomach into the first part of the small intestine or inflating a long balloon in the opening between the stomach and small intestine to improve the emptying of the stomach. Our aim was to investigate whether combining these two treatment methods would enhance the overall therapeutic benefits to treat delayed gastric emptying. Patients with esophageal cancer undergoing esophagectomy have an improved survival over time, however adverse events associated with the use of a gastric conduit are increasingly being reported. Delayed gastric emptying (DGE) is an esophagectomy-related complication which can decreased quality of life by causing debilitating gastrointestinal symptoms and malnutrition. The aim of our study was to evaluate the effect of endoscopic intrapyloric botulinum (BT) injection in combination with pyloric balloon dilation in patients with DGE following distal esophagectomy at our tertiary cancer center. Patients with a prior history of distal esophagectomy who had also undergone endoscopic BT injection with pyloric balloon dilation by a single endoscopist between 2007 and 2017 were included in the study. One hundred units of BT were injected endoscopically into the pylorus in four quadrants using an injection needle. Following BT injection, a standard through-the-scope balloon was passed to the pylorus and inflated to a maximum diameter of 12–20 mm. For patients who underwent repeat procedures, the symptomatic outcomes were assessed and documented by the endoscopist; for the other patients, the electronic medical records were reviewed. A total of 21 patients undergoing 44 endoscopic intrapyloric botox injections combined with balloon dilatations were identified. The patients underwent the procedures at a median of 22 months (range, 1–108 months) after esophagectomy. The procedures were performed only once in 43% of the patients; 43% patients underwent the procedure twice, while 14% had it multiple times (>2). Overall, intrapyloric BT injection coupled with balloon dilation was a safe procedure, without any major immediate or delayed (1 month) procedure-related adverse events. Eighteen patients (85%) reported a significant overall improvement in symptoms from the initial presentation. One patient (5%) showed no improvement, whereas in two (10%) patients responses were not available. In our particular cohort of patients, the interventions of endoscopic intrapyloric BT injection with pyloric balloon dilation proved to be very beneficial, leading to significant symptomatic improvement. The balloon dilation after BT injection might have resulted in better diffusion of the BT into the pyloric sphincter complex, possibly increasing its therapeutic effects. Further prospective studies are needed to validate these results. [ABSTRACT FROM AUTHOR]

Background: There are many well-described potential gastrointestinal (GI) side effects of pancreatic resection that can cause patients to suffer from chronic malabsorption, diarrhea, and persistent nausea. These GI symptoms can affect postoperative recovery, initiation of adjuvant therapy, and overall quality of life (QOL). The purpose of this study is to quantify the incidence of post-procedural complications and identify patients at higher risk for experiencing GI dysfunction after pancreatectomy.Methods: A retrospective review of patients who underwent pancreatic resection at a single institution between January 2014 and December 2019 was performed. Demographics, operative factors, and postoperative gastrointestinal symptomatology and treatments were obtained by chart review. Significance tests were performed to compare GI dysfunction between patient subgroups.Results: A total of 545 patients underwent pancreatic resection; within the cohort 451 patients (83%) underwent a pancreaticoduodenectomy (PD) and the most common indication was pancreatic adenocarcinoma. Two-thirds of patients (67%) reported gastrointestinal symptoms persisting beyond hospitalization. Only 105 patients (20%) were referred to gastroenterology for evaluation with 30 patients (5.5%) receiving a formal diagnosis. Patients who underwent PD were more likely to report GI symptoms and patients who identified as Caucasian were more likely to be referred to gastroenterology for evaluation.Conclusions: Gastrointestinal dysfunction after pancreatic resection occurs frequently yet only a small percentage of patients are referred for formal testing and diagnosis. There also appears to be a racial difference in referral patterns. Patients would benefit if earlier attention was dedicated to the diagnosis and corresponding treatment for postoperative digestive health disorders to optimize treatment planning and QOL. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). There is currently no widely accepted procedure for PD to reduce the incidence of DGE. Our institution attempts to perform subtotal gastrectomy in patients undergoing PD to reduce DGE. Here we aimed to evaluate the effectiveness and safety of PD with subtotal gastric resection.Methods: Patients who underwent PD between January 2014 and December 2021 were reviewed. They were stratified by extent of gastrectomy into a conventional PD group (PD that resected approximately 1/3 of the distal stomach) and a subtotal gastrectomy PD group (PD that resected approximately 3/4 of the distal stomach), which were compared in terms of intraoperative and postoperative parameters.Result: From January 2014 to December 2021, a total of 512 patients underwent PD in the Department of Hepatobiliary Surgery, Peking University People's Hospital. Nineteen patients were excluded from this study due to benign disease. A total of 493 patients were included, with 378 in the conventional PD group and 115 in the subtotal gastrectomy PD group. Compared with the conventional PD group, the subtotal gastrectomy PD group had a lower incidence of DGE (8.7% vs. 17.7%, p = 0.019), and a shorter hospital stay. Multivariate analysis showed that conventional PD and higher body mass index were independent risk factors for grade B/C DGE.Conclusion: This study showed that, compared with conventional PD, subtotal gastrectomy PD can reduce the incidence of DGE and shorten the length of hospital stay. At the same time, subtotal gastrectomy PD is comparable to conventional PD in terms of surgical safety. Furthermore, high BMI is an independent risk factor for postoperative DGE. [ABSTRACT FROM AUTHOR]

Purpose: Clinical significance of reduced vagal activity following pulmonary vein isolation (PVI) for atrial fibrillation (AF) remains unclear. Periesophageal vagal nerve injury following PVI may be a powerful contributing factor of decreased vagal tone. Methods: Drug‐refractory 51 AF patients (31 males, 64 ± 11 years), who underwent successful PVI, were enrolled. We performed esophagogastroduodenoscopy 2 days after PVI and assessed delayed gastric emptying (DGE). Additionally, the coefficient of variance of R-R interval (CVRR) as a surrogate for vagal tone was measured before PVI, as well as at 1 day and 3 months after PVI. The patients were divided into two groups, patients with DGE and patients without DGE, and changes in CVRR were compared. Results: After PVI, 12 out of 51 patients (23.5%) had DGE. The baseline CVRR did not differ between the patients with (n = 12) and those without (n = 39) DGE (median 3.13%, interquartile range 1.69–5.13 vs. median 3.76%, interquartile range 2.96–5.90, P = 0.297). However, CVRR at 1 day after PVI was significantly lower in the patients with DGE than in those without (median 1.49%, interquartile range 0.90–2.19 vs. median 2.59%, interquartile range 1.58–3.86, P = 0.035), and then CVRR at 3 months became similar between the two groups, suggesting that the two groups had different changes in vagal tone after PVI. The recurrence of AF was similar at 3–6 months after PVI between the two groups. Conclusions: A significantly decreased CVRR immediately after PVI is a sign of DGE incidence, implying collateral damage to the esophagus. [ABSTRACT FROM AUTHOR]

Purpose: Pain is considered a major clinical and socioeconomic problem worldwide. Delayed gastric emptying rates allegedly influence the suitability of pain-relief medications in patient populations such as the elderly and individuals with diabetes. Faster pain relief was reportedly achieved by using a fast-dissolving paracetamol (FD-APAP) formulation. This study aims to gain insights to healthcare professionals' (HCPs) perspectives towards using FD-APAP in addressing barriers of pain relief in patient populations susceptible to delayed gastric emptying rates. Patients and Methods: A two-step modified Delphi consensus study was conducted among a panel of 10 general practitioners (GPs) and four endocrinologists. The first step comprises in-depth discussions around evidence relevant to FD-APAP for pain management in patient populations with delayed gastric emptying rates (elderly/diabetics). The second step (a survey) was based on the summarized input from the first step. Consensus was accepted upon ≥ 70% agreement. Perspectives on pain management by FD-APAP for elderly patients were explored among GPs, while those for diabetic patients were explored among GPs and endocrinologists. Results: Consensus was achieved, whereby all panel members found FD-APAP to be favorable and relevant for pain management in the elderly and the diabetic patient populations. GPs additionally raised the consensus on the importance of considering comorbidities associated with diabetes while having minimal complications during pain management. Conclusion: The panel found the faster disintegration and absorption of FD-APAP relevant and useful for patients with delayed gastric emptying, wherein, pain in the elderly and those with diabetes could be treated effectively with limited side-effects. [ABSTRACT FROM AUTHOR]

Background and aims: There has been interest in the use of pyloric therapies for the treatment of refractory gastroparesis. However, data on endoscopic pyloric dilation are scarce. We aimed to assess the efficacy and safety of this procedure in refractory gastroparesis. Methods: We performed a retrospective analysis of 47 patients referred for refractory gastroparesis, confirmed by gastric emptying scintigraphy, and treated with endoscopic pyloric through-the-scope balloon dilation. The primary endpoint was the effectiveness of the procedure, evaluated with the Gastric Cardinal Symptom Index (GCSI) at 2 and 6 months. Results: A clinical response, defined by a 1.0 point decrease in the GCSI score, was observed in 25 patients at 2 months (53%) and in 19 patients at 6 months (40%). The mean GCSI score decreased significantly at 2 and 6 months compared to the preoperative score (3.9 ± 0.87 vs 2.3 ± 1.37 and 3.9 ± 0.87 vs 2.9 ± 1.27, respectively; p < 0.0001). No complication was observed. Nine patients had a delayed relapse at 1 year. A second dilation was performed for eight patients and it was effective in five of them (63%). The mean follow-up time of the patients was 27.0 ± 10.4 months. At 2 years, 15 patients still experienced improvement following this treatment (32%). No predictive factor of clinical response was identified. Conclusion: The efficacy of pyloric dilation is 53% at 2 months, with sustained improvement in one third of patients at 2 years. This treatment should be considered as an alternative option to pyloromyotomy. [ABSTRACT FROM AUTHOR]

Delayed gastric emptying (DGE) ranks as one of the most frequent complications in pancreatic surgery. It leads to increased costs for healthcare systems, lengthened hospital stays and reduced quality of life. Data about DGE after distal pancreatectomy (DP) are scarce. The StuDoQ|Pancreas registry of the German Society of General and Visceral Surgery provided data of patients who underwent distal pancreatectomy from 1 January 2014 to 31 December 2018. The retrospective evaluation included comprehensive data: 1688 patients were enrolled; DGE occurred 160 times (9.5%); grade "A" was reported for 98 (61.3%), grade "B" for 41 (25.6%) and grade "C" for 21 (13.1%) patients. In univariate analysis pancreatic fistulas were associated with higher frequencies of intraabdominal abscesses (9.1% vs. 2%, p > 0.001), postpancreatectomy haemorrhage (8.1% vs. 3.7%, >0.001) and DGE (14.5% vs. 6%, p < 0.001). According to multivariate analysis, "abscesses with invasive therapy" (p < 0.001), "other surgical complications" (p < 0.001), prolonged "stays in ICU" (p < 0.001), lengthened duration of surgery (p < 0.001) and conventional surgery (p = 0.007) were identified as independent risk factors for DGE. Perioperative and postoperative factors were identified as risk factors for DGE. Following research should examine this highly relevant topic in a prospective, register-based manner. As there is no causal therapy for DGE, its avoidance is of major importance. [ABSTRACT FROM AUTHOR]

Purpose: Pylorus-preserving pancreatoduodenectomy (PPPD) has been the gold standard for pancreatic head lesion resection for several years. Some studies have noted that it involves more delayed gastric emptying (DGE) than classical Whipple (i.e., pancreatoduodenectomy with antrectomy). Our working hypothesis was that the classical Whipple has a lower incidence of DGE. We aimed to compare the incidence of DGE among pancreatoduodenectomy techniques. Methods: This pragmatic, randomized, open-label, single-center clinical trial involved patients who underwent classical Whipple (study group) or PPPD (control group). Gastric emptying was clinically evaluated using scintigraphy. DGE was defined according to the International Study Group of Pancreatic Surgery (ISGPS) criteria. The secondary endpoints were postoperative morbidity, length of hospital stay, anthropometric measurements, and nutritional status. Results: A total of 84 patients were randomized (42 per group). DGE incidence was 50% (20/40, 95% confidence interval (95% CI): 35–65%) in the study group and 62% (24/39, 95% CI: 46–75%) in the control group (p = 0.260). No differences were observed between both groups regarding postoperative morbidity or length of hospital stay. Anthropometric measurements at 6 months post-surgery: triceps fold measurements were 12 mm and 16 mm (p = 0.021). At 5 weeks post-surgery, triceps fold measurements were 13 mm and 16 mm (p = 0.020) and upper arm circumferences were 26 cm and 28 cm (p = 0.030). No significant differences were observed in nutritional status. Conclusion: DGE incidence and severity did not differ between classical Whipple and PPPD. Some anthropometric measurements may indicate a better recovery with PPPD. Trial registration: ClinicalTrials.gov Identifier: NCT03984734. [ABSTRACT FROM AUTHOR]

Equine squamous gastric disease (ESGD), pyloric outflow obstruction and delayed gastric empty... Squamous gastric disease in horses is attributable to increased exposure of the squamous mucosa to acid and is comparable to gastric ulceration of the I pars oesophagea i in pigs and gastro-oesophageal reflux disease (GERD) in people. Affected horses do not appear to have difficulty emptying liquids from their stomach, and therefore, they rarely present with fluid distention of the stomach and do not develop secondary squamous gastric disease or gastro-oesophageal reflux. Keywords: horse; delayed gastric emptying; ESGD; EGGD; gastric dysmotility; gastroparesis EN horse delayed gastric emptying ESGD EGGD gastric dysmotility gastroparesis 460 466 7 08/04/22 20220901 NES 220901 The case report by Witt et al. (2022) in this issue of I Equine Veterinary Education i describes delayed gastric emptying in a foal secondary to squamous gastric disease. In man, gastric diverticula are classified as true diverticula which are congenital; and acquired "traction" diverticula which are thought to be caused by perigastric adhesions from concurrent diseases, such as peptic ulcer disease (Marano et al., 2013). gl Secondary squamous gastric disease is less common and occurs as a direct consequence of delayed gastric emptying. [Extracted from the article]

Delayed gastric emptying (DGE) is the most common complications after Whipple pancreaticoduodenectomy (WPD). Braun enteroenterostomy (BEE) is a useful technique to divert bile from the stomach. We recently started doing binding pancreaticogastrostomy (BPG) for pancreatic reconstruction after WPD, and the most frequent complication was DGE. The aim was to study the effect of Braun enteroenterostomy on delayed gastric emptying in binding pancreaticogastrostomy following Whipple pancreaticoduodenectomy. The study included all patients who underwent BEE in BPG following WPD from February 2014 till May 2016 at a tertiary care center. Braun enteroenterostomy was constructed approximately 25 cm distal to the gastrojejunostomy by a side-to-side hand-sewn or stapled anastomosis. Delayed gastric emptying was defined as per International Study Group of Pancreatic Surgery (ISGPS) definition. All patient data including patient demographics, type of procedure performed, complications, mortality, hospital stay, postoperative interventions, or re-operations were documented. There were 13 (30.95%) patients with DGE A and 4 (9.52%) patients with DGE B, and no patients had DGE C. Hence, there were only 4 patients (9.52%) with clinically significant DGE. Addition of Braun enteroenterostomy reduces delayed gastric emptying after Whipple pancreaticoduodenectomy with binding pancreaticogastrostomy. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) remains the most frequent complication following pancreatoduodenectomy (PD). The present study investigates the influence of delayed gastric emptying on cancer-specific survival after PD. Methods: We included 267 patients who underwent PD between 2014 and 2021. They were analyzed regarding demographic factors, pre- and perioperative characteristics, surgical complications, and long-term survival. Results: Patients with a higher Charlson Comorbidity Index (CCI) or pre-existing pulmonary disease suffered significantly more from DGE. When experiencing PPH, a prolonged hospital stay, or major overall complications (Clavien-Dindo °III-V) were more common in the DGE group. Tumor size over 3 cm negatively affected survival. Conclusions: DGE has no influence on long-term survival in PDAC patients, although it prolongs hospital stay. [ABSTRACT FROM AUTHOR]

Background: Pyloric botulinum toxin injection has improved symptoms in children with delayed gastric emptying. We aimed to determine the clinical response to combined endoscopic intra-pyloric botulinum toxin injection and pyloric balloon dilation (IPBT-BD) in patients with dyspepsia. Methods: Electronic medical records were reviewed to gather demographic data, symptoms, and follow-up on patients with dyspepsia. Cases were defined as those who underwent IPBT-BD in addition to their ongoing management. Controls received pharmacotherapy, behavioral intervention, or dietary management alone. Clinical response was defined as no change, partial, or complete improvement in symptoms within 12 months. Propensity score matching based on age, gender, and symptom duration was used to pair cases and controls. Results: In total, 79 cases and 83 controls were identified. After propensity matching, 63 patients were included in each group. The mean age for cases was 14.5 ± 3.9y; 62% were females and 98% were Caucasian. Further, 83% of 46 cases and 94% of 49 controls who had scintigraphy scans showed delayed gastric emptying. After matching, 76% of cases showed partial or complete improvement compared with 49% controls within 12 months (P = 0.004). Younger children tended to respond more favorably to the procedure (P = 0.08). Conclusions: In our propensity-matched analysis, combined IPBT-BD in addition to pharmacotherapy, behavioral, or dietary management clearly showed a benefit over these modalities alone. This favorable response lasted up to 12 months. [ABSTRACT FROM AUTHOR]

Background: Gastroparesis is common after lung transplantation and is associated with worse transplant outcomes, including the development of chronic lung allograft dysfunction (CLAD). This study sought to identify the prevalence, risk factors, and outcomes associated with a new diagnosis of gastroparesis after lung transplantation.Methods: This was a single-center retrospective study of patients who underwent lung transplantation in 2008-2018. The primary outcome was a new diagnosis of gastroparesis within 3 years of transplant. Secondary outcomes included a new diagnosis of gastroesophageal reflux and the association between gastroparesis and both post-transplant survival and CLAD-free survival. Multivariable logistic regression was used to compare diagnosis of gastroparesis and gastroesophageal reflux, while multivariable Cox proportional hazards models were used to analyze gastroparesis and post-transplant outcomes.Results: Of 616 patients with no prior history of gastroparesis, 107 (17.4%) were diagnosed with delayed gastric emptying within 3 years of transplant. On multivariable logistic regression, black race (OR 2.16, 95% CI 1.18-3.98, p = 0.013) was significantly associated with a new diagnosis of gastroparesis. Age, sex, history of diabetes, connective tissue disease, type of transplant, diagnosis group, renal function, and body mass index were not predictive of gastroparesis post-transplant. Gastroparesis was significantly associated with CLAD (HR 1.76, 95% CI 1.20-2.59, p = 0.004), but not with overall mortality (HR 1.16, p = 0.43).Conclusion: While gastroparesis is common after lung transplantation, it remains difficult to predict which patients will develop these complications post-transplant. Black patients were more likely to be diagnosed with gastroparesis after adjusting for relevant confounders. Gastroparesis is associated with increased risk of CLAD, and further studies are needed to assess whether early detection and treatment can reduce the incidence of CLAD. [ABSTRACT FROM AUTHOR]

Purpose: Esophagectomy with gastric tube reconstruction is often complicated postoperatively by duodenogastric reflux and/or delayed gastric emptying and the accompanying symptoms, leading to patients being dissatisfied with their quality of life (QOL). Medical interventions to relieve patients of their symptoms are rarely effective. We began, in 2018, performing double tract-like gastric tube reconstruction, and, in a pilot study, we compared postoperative QOL between patients in whom this experimental reconstruction was performed and those in whom conventional reconstruction was performed. Methods: Included in the study were 33 patients who underwent thoracoscopic McKeown esophagectomy with two- or three-field lymph node dissection for thoracic esophageal cancer between April 2015 and March 2020. A gastric tube about 4 cm in width was created in all patients, and in 14 of the patients (DT group), a double tract was appended by anastomosing the elevated jejunum to the anterior wall of the gastric tube, QOL was assessed 10–14 months later by means of the DAUGS-32 questionnaire, and bile reflux and the presence or absence of food residue were assessed by upper gastrointestinal endoscopy. Results: DAUGS-32 food passage dysfunction, nausea and vomiting, and reflux symptoms scores were significantly lower in the DT group than in the conventional reconstruction group. There was no significant between-group difference in the incidence of postoperative complications. No food residue was seen in DT patients' gastric tube, and no reflux esophagitis was observed. Conclusion: Double tract-like gastric tube reconstruction shows promise as an effective means of improving patients' post-esophagectomy QOL. [ABSTRACT FROM AUTHOR]

Background: Early nasogastric tube (NGT) removal is a component of enhanced recovery after surgery (ERAS) protocol for esophagectomy. The aim of this study is to assess a protocol-driven application of UGI contrast study to facilitate early NGT removal and direct a standardized therapeutic response in patients with evidence for delayed gastric conduit emptying (DGCE).Methods: All patients undergoing esophagectomy between January 2017 and October 2019 were prospectively enrolled. Esophageal resections were performed through different surgical approaches involving gastric conduit reconstruction. A standardized clinical protocol (SCP) was systematically applied, which targeted a UGI contrast study on POD 2-3 to allow immediate NGT removal or initiate DGCE protocols.Results: This study enrolled 50 patients undergoing open Ivor Lewis (42%), left thoracoabdominal (46%), and three-field procedure (12%) with gastric conduit reconstruction and either upper thoracic (66%) or cervical (34%) anastomosis. Jejunostomy was routinely placed while pyloric procedures were not performed. Patients achieving targeted contrast study (86%) demonstrated significantly earlier NGT removal (p-value 0.010), oral protocol initiation (0.001), and decreased length of hospital stay (6 vs 10 days, 0.024). Four patients (8%) presented with radiology signs of DCGE and underwent protocoled treatment, eventually achieving discharge similar to the overall study population (7 vs 8.5 days).Conclusions: Protocol-driven UGI contrast study can effectively provide objective data facilitating early NGT removal and discharge. Patients with DGCE can successfully undergo intervention to improve conduit emptying and adhere to ERAS discharge goals. [ABSTRACT FROM AUTHOR]

Simple Summary: Over the last decades the number of obese patients has been increasing. Not only is obesity associated with other diseases such as cardiovascular diseases, diabetes and asthma but obese patients are also at a higher risk for developing different types of cancers, for instance pancreatic cancer with a consecutive increased need for pancreatic surgery. Even though it is not life threatening, impaired gastric motility, also known as delayed gastric emptying, has still remained the most common complication after pancreatic surgery. However, the data about obesity on postoperative outcome after pancreatic surgery are inconsistent, specifically in relation to delayed gastric emptying. The goal of this study was to investigate the impact of obesity on postoperative outcome, specifically on delayed gastric emptying, after pancreatic surgery. Our data show no difference in the occurrence and severity of delayed gastric emptying in patients with obesity compared to non-obese patients. Moreover, the overall mortality rate did not differ between the two groups. In summary, our data show that obese patients are not put at a higher risk in regard to postoperative outcome, which makes pancreatic surgery a feasible procedure in the obese patient, specifically in relation to delayed gastric emptying. Background: The data about obesity on postoperative outcome after pancreatoduodenectomy (PD) are inconsistent, specifically in relation to gastric motility and delayed gastric emptying (DGE). Methods: Two hundred and eleven patients were included in the study and patients were retrospectively analyzed in respect to pre-existing obesity (obese patients having a body mass index (BMI) ≥ 30 kg/m2 vs. non-obese patients having a BMI < 30 kg/m2, n = 34, 16% vs. n = 177, 84%) in relation to demographic factors, comorbidities, intraoperative characteristics, mortality and postoperative complications with special emphasis on DGE. Results: Obese patients were more likely to develop clinically relevant pancreatic fistula grade B/C (p = 0.008) and intraabdominal abscess formations (p = 0.017). However, clinically relevant DGE grade B/C did not differ (p = 0.231) and, specifically, first day of solid food intake (p = 0.195), duration of intraoperative administered nasogastric tube (NGT) (p = 0.708), rate of re-insertion of NGT (0.123), total length of NGT (p = 0.471) or the need for parenteral nutrition (p = 0.815) were equally distributed. Moreover, mortality (p = 1.000) did not differ between the two groups. Conclusions: Obese patients do not show a higher mortality rate and are not at higher risk to develop DGE. We thus show that in our study, PD is feasible in the obese patient in regard to postoperative outcome with special emphasis on DGE. [ABSTRACT FROM AUTHOR]

Background: Delayed gastric emptying (DGE) after distal gastrectomy impacts patients' nutritional status and quality of life. The current treatments of DGE seem unsatisfactory or need invasive interventions. It is unknown whether transcutaneous electroacupuncture (TEA) is effective in treating DGE. Methods: A total of 90 eligible participants who underwent distal gastrectomy will be randomly allocated to either the TEA group (n = 60) or the sham transcutaneous electroacupuncture (sham-TEA) group (n = 30). Each participant will receive TEA on the bilateral acupoints of Zusanli (ST36) and Neiguan (PC6) for 4 weeks. The primary outcomes will be the residual rates of radioactivity in the stomach by gastric scintigraphy and total response rates. The secondary outcomes will be endoscopic features, autonomic function, nutritional and psychological status, serum examination, and quality of life (QoL). The adverse events will also be reported. The patients will be followed up 1 year after the treatment. Discussion: The findings of this randomized trial will provide high-quality evidence regarding the efficacy and safety of long-term TEA for treating DGE after distal gastrectomy. Trial registration: Chinese Clinical Trial Registry ChiCTR2000033965. Registered on 20 June 2020 [ABSTRACT FROM AUTHOR]

Background: The endoluminal functional lumen imaging probe (FLIP) can be used to obtain real-time measurements of the diameter (Dmin), cross-sectional area (CSA), and distensibility of the pylorus before and after peroral pyloromyotomy (POP), an emerging endoscopic treatment for delayed gastric emptying. Our study aims to report our single-center experience in performing POP with FLIP measurements before and after pyloromyotomy. Methods: A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic and perioperative data, including intraoperative FLIP measurements of the pylorus before and after POP, were analyzed. Measurements were compared using paired t tests. Results: Thirty-four patients underwent POP between February 2017 and July 2020. Twenty-three (67.7%) patients were male and the average age was 59 years. The etiology of delayed gastric emptying was post-vagotomy in 22 patients, idiopathic gastroparesis in 7 patients, and diabetic gastroparesis in 5 patients. There were no significant differences in pre-myotomy or post-myotomy FLIP measurements when comparing the post-vagotomy versus the gastroparesis groups. There were significant increases in Dmin, CSA, and distensibility index when comparing pre-myotomy and post-myotomy readings for all patients (all p < 0.001). At follow-up, 64.7% of patients reported resolution of all symptoms. Conclusion: POP is an effective intervention in patients with delayed gastric emptying. Significant changes in FLIP measurements before and after POP suggest that FLIP may be a useful adjunct in guiding the management of delayed gastric emptying. [ABSTRACT FROM AUTHOR]

Background: Pylorus-preserving pancreaticoduodenectomy (ppPD) is a standard surgical procedure for the treatment of resectable neoplasms of the periampullary region. One of the most common postoperative complications after ppPD is delayed gastric emptying (DGE) which reduces quality of life, prevents a timely return to a solid oral diet and prolongs the length of hospital stay. In a retrospective analysis, intraoperative endoluminal pyloromyotomy was associated with a reduced rate of DGE. The aim of this study is to investigate the effect of intraoperative endoluminal pyloromyotomy on postoperative DGE after ppPD in a randomised and controlled setting.Methods: This randomised trial features parallel group design with a 1:1 allocation ratio and a superiority hypothesis. Patients with a minimum age of 18 years and an indication for ppPD are eligible to participate in this study and will be randomised intraoperatively to receive either endoluminal pyloromyotomy or atraumatic stretching of the pylorus. The sample size calculation (n=64 per study arm) is based on retrospective data. The primary endpoint is the rate of DGE within 30 days. Secondary endpoints are quality of life, operation time, estimated blood loss, length of hospital stay, morbidity and mortality.Discussion: DGE after ppPD is a common complication with an incomplete understood aetiology. Prevention of DGE could improve outcomes and enhance quality of life after one of the most common procedures in pancreatic surgery. This trial will expand the existing evidence on intraoperative pyloromyotomy, and the results will provide additional data on a simple surgical technique that could reduce the incidence of postoperative DGE.Trial Registration: German Clinical Trials Register DRKS00013503 . Registered on 27 December 2017. [ABSTRACT FROM AUTHOR]

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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. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Gastric emptying delay after oesophagectomy may occur in conduits exposed to pleural forces of respiration or anatomic obstruction. Remedial operations addressing both causes are rarely reported. The study aim was to categorize severe gastric conduit obstruction (GCO) and report the outcome of surgical revision. METHODS A single-institution, retrospective study of gastric conduit revision following oesophagectomy for oesophageal cancer investigated incidence, risk factors and categories of conduit obstruction. Evaluation consisted of contrast studies, computed tomogram and endoscopy. Interventions were categorized according to obstructive cause and included pyloroplasty, hiatal hernia reduction and thoraco-abdominal conduit repositioning. RESULTS Among 1246 oesophagectomies over a 17-year period, 14 patients (1.1%) required post-oesophagectomy relief of GCO. Two additional patients presented after oesophagectomy elsewhere. Before oesophagectomy, 18.8% (3/16) and 62.5% (10/16) of patients were on chronic opioid and psychotropic medications, respectively. Distinct anatomic features separated obstruction into 3 categories: pyloric in 31% (5/16), extrinsic in 12.5% (2/16) and combined in 56.3% (9/16). Operative revision led to complete symptom resolution in 50% (8/16) of patients and symptom improvement in 43.8% (7/16) of patients. One patient (1/16, 6.25%) in the combined obstruction group did not improve with surgical revision. CONCLUSIONS GCO after oesophagectomy rarely requires surgical revision. Potential association with medications affecting oesophageal and gastric motility requires further investigation. Classification of obstruction identifies a patient subset with lower success after surgical revision. [ABSTRACT FROM AUTHOR]

Background: Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. Purpose: The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. Conclusions: Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management. [ABSTRACT FROM AUTHOR]

Introduction: While Enhanced Recovery After Surgery (ERAS) has been widely implemented in upper and lower gastrointestinal operations, its application after whipple pancreaticoduodenectomy remains at an experimental level and has not been accepted as a standard of care in most centers including ours. Aim: To assess the merits and safety of ERAS after Whipple pancreaticoduodenectomy. Materials and Methods: This was a pilot study (prospective cohort study design) conducted at Christian Medical College Vellore, Tamil Nadu, India. Total 30 consecutive patients who underwent whipple procedure between September 2016 and May 2017 were managed using the ERAS protocol in the postoperative period. The operations were performed by one of the three senior surgeons and a standard method of reconstruction was followed. All patients underwent a feeding jejunostomy as part of the operation. The primary end point was duration of hospital stay and secondary end points were number of days required for urinary catheter removal, ambulation, cessation of intravenous fluids, discontinuation of infusional analgesia, removal of nasogastric tube, normal oral intake and drain removal. The rates of complications including Postoperative Pancreatic Fistula (POPF), Delayed Gastric Emptying (DGE), intra abdominal collection, post pancreatectomy haemorrhage and death were also calculated and compared with previous year data to assess the safety of ERAS protocol. Results: Mean age of patients was 53.9 years. There were 26 males and four females in this study. Total 21 out of the 30 patients had ampullary adenocarcinoma. More than 80% of the patients achieved milestones like urinary catheter removal, ambulation, cessation of i.v. fluids and infusional analgesia. Total 14 out of 30 (46.6%) patients tolerated normal diet by day 6 and 17 patients were managed without utilising the feeding jejunostomy. Drains were removed only in seven patients as per protocol. The mean hospital stay was 20.1 in comparison to the mean stay of the previous year which was 22.8 days. However, 15 patients were fit for discharge by day 15 based on discharge criteria, but were not discharged as the patients wanted to stay longer. There was no increase in morbidity or mortality in comparison to the previous year. Conclusion: The implementation of ERAS protocol appears to have no negative impact in the postoperative recovery in the patients with a potential for shortening hospital stay without added postoperative morbidity. [ABSTRACT FROM AUTHOR]