Delayed Gastric Emptying Research Articles

Evaluation of an enhanced recovery after surgery protocol for pancreaticoduodenectomy in a tertiary referral hospital: a retrospective cohort study

Purpose: The implementation of an enhanced recovery after surgery (ERAS) protocol results in accelerated perioperative recovery, reduced length of hospital stay (LOS) and in-hospital costs. The primary endpoint of this study is to evaluate the different targets of the ERAS protocol separately. The secondary endpoints are the 30-day reoperation rate, readmission rate and mortality. Method: This single centre retrospective analysis reviews the data of 154 patients who underwent a pancreaticoduodenectomy between August 2016 and December 2019. As per ERAS protocol, the epidural analgesia was stopped on postoperative day (POD)2, the nasogastric tube (NGT) removed on POD3 and regular food tolerated by POD5. Drains were removed on POD2, POD3 and the soft drain along the pancreatic anastomosis between POD3-10. Results: Epidural analgesia was discontinued on POD2 in 26 patients (17.7%), the NGT removed on POD3 in 74 patients (49.0%), and regular food started by POD5 in 52 patients (34.9%). The lateral drain was removed in 81 patients (52.9%) on POD2, the medial drain in 39 patients (26.2%) at POD3, the soft drain in 95 patients (61.7%) between POD3 and POD10. Nine patients (5.8%) had post-pancreatectomy haemorrhage (PPH), 14 (9.1%) had a postoperative pancreatic fistula grade B or C (POPF), 5 (3.3%) had a bile leakage, and 44 (28.6%) experienced delayed gastric emptying (DGE). The 30-day readmission rate was 8.4%, the reoperation rate was 10.4%, and the in-hospital mortality 1.3%. Conclusion: Efficient implementation requires strict follow-up of all included ERAS elements, but should not be restricted to low-risk patients. Delayed gastric emptying and POPF are predictors for a prolonged LOS. Length of hospital stay is influenced by multiple factors and therefore not a good parameter to evaluate implementation of an ERAS protocol.

Impact of Neoadjuvant Therapy on Postoperative Pancreatic Fistula: A Systematic Review and Meta-analysis

Introduction: The use of neoadjuvant therapy (NAT) for pancreatic cancer is increasing, although its impact on postoperative pancreatic fistula (POPF) is variably reported. This systematic review and meta-analysis aimed to assess the impact of NAT on POPF. Methods: A systematic literature search until October 2019 identified studies reporting POPF following NAT (radiotherapy, chemotherapy or chemoradiotherapy) vs. upfront resection. The primary outcome was overall POPF. Secondary outcomes included Grade B/C POPF, delayed gastric emptying (DGE), postoperative pancreatic haemorrhage (PPH), and overall and major complications. Results: The search identified 24 studies: pancreaticoduodenectomy (PD), 19 studies (n=19,893); distal pancreatectomy (DP), 5 studies (n=477). Local staging was reported in 17 studies, with borderline resectable and locally advanced disease comprising 6% (0 - 100%) and 1% (0 - 33%) of the population, respectively. For PD, any NAT was significantly associated with lower rates of overall POPF (OR: 0.57, p< 0.001) and Grade B/C POPF (OR: 0.55, p< 0.001). In DP, NAT was not associated with significantly lower rates of overall or Grade B/C POPF. Conclusion: NAT is associated with significantly lower rates of POPF after PD but not after DP. Further studies are required to determine whether NAT should be added to POPF risk calculators.

Involvement of serotonergic pathways in gastric dysmotility induced by fat burning nutritional supplements in mice

Fat burners are a category of nutritional supplements that are claimed to increase the metabolism and promote greater energy expenditure, leading to weight loss. However, little is known about the side effects on gastrointestinal motility. In this study, we evaluated the effect of ingestion with a fat burner named Thermbuterol® (THERM) on the gastric motility and food behavior of mice. THERM compounds were identified using nuclear magnetic resonance (NMR). Mice received variable doses of THERM (10, 50, 100 or 300 ​mg/kg, p.o.) or NaCl 0.15 ​M (control). Gastric emptying (GE) was assessed using the phenol red technique. Another set of mice was pretreated with intraperitoneal administration of hexamethonium (HEXA, 10 ​mg/kg), prazosin (PRAZ, 0.25 ​mg/kg), propranolol (PROP, 2 ​mg/kg), parachlorophenylalanine (PCPA, 300 ​mg/kg) or ondansetron (ONDA, 50 ​μg/kg) 30 ​min before THERM treatment for evaluation of GE. We assessed the gastrointestinal responsiveness in vitro as well as THERM's effects on food behavior. Caffeine was the major compound of THERM, identified by NMR. THERM 100 and 300 ​mg/kg decreased GE compared to the respective controls. Pretreatment with PRAZ or PROP did not prevent gastric dysmotility induced by THERM 100 ​mg/kg. However, the pretreatment with HEXA, ONDA or PCPA prevented GE delay induced by THERM. In vitro, THERM relaxed contractions in strips of longitudinal gastric fundus and duodenum. THERM also increased food intake, which was prevented by PCPA and ONDA treatments. THERM decreased GE of a liquid and increased food intake in mice, a phenomenon mediated by the autonomic nicotinic receptors and serotoninergic receptor.

Radiologic intervention due to delayed gastric emptying after pylorus preserving gastrectomy for gastric cancer does not affect pyloric function.

The purpose of this study is to evaluate whether radiologic intervention in the pylorus decreases its function for delayed gastric emptying (DGE) patients after pylorus preserving gastrectomy (PPG) for gastric cancers and to determine the optimal interventional algorithm. PPG patients who underwent intervention for DGE from January 2013 to December 2017 and a control group using propensity score matching were identified. Pyloric function was compared by subjective symptoms, postoperative upper gastrointestinal series at 3 months (short-term function), and esophagogastroduodenoscopy findings at 12 months (long-term function). Serum albumin levels and body weight change, 6 months and 12 months postoperatively, were compared to evaluate nutritional status. Interventional success rate, mean hospital stay, and recurrence of DGE were analyzed to determine the optimal intervention plan. Fifty-one out of 677 patients (7.53%) received intervention. There was no difference in pyloric function and nutritional status between the intervention and control groups. The interventional success rate for first-time balloon dilatation was 41.7% (20/48). If a second intervention was required and balloon dilatation was done, the success rate was 45.5% (5/11). However, if stent insertion was done, the success rate was 100% (17/17). Subsequent stent insertion after balloon dilatation resulted in a shorter mean hospital stay. Intervention including stent insertion had a lower recurrence of DGE than balloon only intervention (1.96% vs. 5.88%, P=0.041). Radiologic intervention did not decrease long-term pyloric function. For treating DGE, if at first balloon dilatation fails, retrievable stent insertion can be considered as a second choice.

Diagnosis and surgical correction of pyloric stenosis in a dog – a case study

Pyloric stenosis, which could occur as a congenital or acquired condition, is more common in dogs when compared with other domestic animals. This condition has not been reported in Sri Lanka probably due to unfamiliarity with it and lack of diagnostic facilities. This communication discusses the clinical signs, radiographic and ultrasonographic findings, and treatment of pyloric stenosis in a one-year old female Cocker Spaniel presented to the Veterinary Teaching Hospital (VTH), Peradeniya. The patient developed projectile vomiting and distended, gas filled abdomen after meals as clinical signs. Survey radiographic findings included the 'gravel sign' in the stomach. In ultrasonography, thickened pylorus was observed. Contrast radiographs after oral administration of barium sulphate suspension showed a delay of gastric emptying. All the above findings suggested that the patient had pyloric stenosis. Complete blood count and serum biochemistry demonstrated no abnormalities. Surgical intervention was performed as treatment, using Fredet-Ramstedt pyloromyotomy together with Heineke-Mikulicz pyloroplasty to clear the obstruction in the pyloric canal. Since there were no post-surgical complications, patient was discharged in 4 days following the surgery. The prognosis was satisfactory and the animal has been healthy after the surgery. The pyloric stenosis observed in this case could be congenital, with hypertrophy and subsequent stenosis gradually worsening over time.

Roux-en-Y and Billroth II Reconstruction after Pancreaticoduodenectomy: A Meta-Analysis of Complications.

Objective To evaluate Roux-en-Y and Billroth II reconstruction following pancreaticoduodenectomy (PD). Methods PubMed, Embase, the Cochrane Library, and the Web of Science were searched to identify randomized controlled trials (RCTs) and controlled clinical trials that compared Roux-en-Y and Billroth II reconstruction following PD up to December 2019. RevMan 5.3 software was used for the statistical analysis. Results Four RCTs and five controlled clinical trials were included, with a total of 1,072 patients (500 and 572 patients in the Roux-en-Y and Billroth II groups, respectively). No significant differences in delayed gastric emptying (DGE), A-grade DGE, B-grade DGE, or C-grade DGE were observed between the Roux-en-Y and Billroth II reconstruction groups after PD (odds ratio [OR] = 1.01, 95% confidence interval [CI]: 0.50–2.03, P = 0.98; OR = 0.49, 95% CI: 0.17–1.45, P = 0.20; OR = 0.63, 95% CI: 0.29–1.38, P = 0.25; and OR = 2.13, 95% CI: 0.38–11.99, P = 0.39). No significant difference in the incidence of postoperative pancreatic fistula, abscess, bile leaks, infection, postoperative bleeding, or the length of the postoperative hospital stay was observed between the Roux-en-Y and Billroth II groups (P > 0.05), but the operation time was significantly different (mean difference [MD] = 31.65, 95% CI: 7.14–56.17, P = 0.01). Conclusions Billroth II reconstruction after PD did not significantly reduce the incidence of DGE or other complications but shortened the operation time compared to Roux-en-Y reconstruction. However, the results must be verified by further high-quality, large RCTs or controlled clinical trials.

Evaluation of an enhanced recovery program for outcome improvement after pancreaticoduodenectomy: A retrospective cohort study

BackgroundThe introduction of the Enhanced Recovery After Surgery (ERAS) protocol after pancreaticoduodenectomy (PD) has led to a reduction in hospital stay (LOS) without compromising surgical outcome. The primary endpoint of this study is to evaluate the adherence to postoperative targets of the ERAS protocol, and to describe short-term surgical outcomes. The secondary endpoints are 30-day readmission rate, reoperation rate and mortality. Materials and methodsThis single centre retrospective analysis reviews all data of patients who underwent a PD in our tertiary referral hospital between August 2016 and December 2019. A total of 170 patients were operated of whom 154 patients were enrolled in the ERAS protocol. As per ERAS protocol, epidural analgesia was stopped on postoperative day (POD) 2, nasogastric tube (NGT) removed on POD3, regular food tolerated by POD5. Drains were removed on POD2 and POD3, the soft drain along the pancreatic anastomosis between POD3-10. ResultsEpidural analgesia was removed on POD2 in 26 patients (17.7%), NGT removed on POD3 in 74 patients (49.0%), regular food tolerated by POD5 in 52 patients (34.9%). The lateral drain was removed in 81 patients (52.9%) on POD2, the medial drain in 39 patients (26.2%) on POD3, the soft drain in 95 patients (61.7%) between POD3 and 10. Nine patients (5.8%) had post-pancreatectomy haemorrhage (PPH), 14 (9.1%) postoperative pancreatic fistula grade B or C (POPF), 5 (3.3%) bile leakage, and 44 (28.6%) delayed gastric emptying (DGE). The 30-day readmission rate was 8.4%, reoperation rate 10.4%, and the in-hospital mortality 1.3%. ConclusionsThe adherence to targets of the ERAS protocol was found to be rather low. Biliary leakage, POPF, DGE, and PPH all led to an adapted ERAS protocol with prolonged LOS. Most complications were detected along the ERAS pathway, indicating that also patients at high risk for complications can be safely included in the ERAS protocol.

Risk-Stratified Pancreatectomy Clinical Pathway Implementation and Delayed Gastric Emptying

BackgroundDelayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD) that impairs recovery and quality of life. The purpose of this study was to assess the impact risk-stratified pancreatectomy clinical pathways (RSPCPs) had on delayed gastric emptying (DGE) and identify factors associated with DGE in a contemporary period. MethodsA single-institution, prospective database was queried for consecutive PDs during July 2011–November 2019. Using international definitions, DGE rates were compared between periods before and after RSPCPs were implemented in 2016, classifying patients according to their postoperative pancreatic fistula (POPF) risk. Risk factors were analyzed to identify modifiable targets. ResultsAmong 724 elective PDs, 552 (76%) were for adenocarcinoma and 172 (24%) for other diagnoses. Of the 197 (27%) patients with DGE, 119 (16%) had type A, 41 (6%) type B, and 38 (5%) type C. In the overall cohort, DGE rates were higher with pylorus-preserving vs. classic hand-sewn reconstruction (odds ratio [OR] − 1.84; p < 0.001), postoperative abscess (OR − 2.54; p = 0.003), and non-white patients (p = 0.007), but lower after implementation of RSPCPs (OR − 0.34, p < 0.001). In the 374 patients treated with RSPCPs, only 17% (n = 65/374) developed DGE. Patients with protocol-compliant NGT removal ≤ 48 h were less likely to experience DGE (OR − 1.46, p = 0.042). ConclusionOur data suggest that implementation of preoperatively assigned RSPCPs as a care bundle was the most important factor in decreasing DGE. These gains were accentuated in patients who underwent early nasogastric tube removal and had a classic hand-sewn gastro-jejunostomy reconstruction. Application of these modifiable factors is generalizable with low implementation barriers.

Safety and efficacy of robot-assisted versus open pancreaticoduodenectomy: a meta-analysis of multiple worldwide centers.

The objective of the study is to compare the safety and efficacy of robot-assisted pancreaticoduodenectomy (PD) with open PD. The PubMed, EMBASE and Cochrane Library databases were searched for the literature available from their respective inception dates up to May 2020 to find studies comparing robot-assisted pancreaticoduodenectomy (RPD) with open pancreaticoduodenectomy (OPD). The RevMan 5.3 statistical software was used for analysis to evaluate surgical outcome and oncology safety. The combination ratio (RR) and weighted mean difference (WMD) and their 95% confidence intervals (CIs) were calculated using fixed-effect or random effect models. 18 cohort studies from 16 medical centers were eligible with a total of 5795 patients including 1420 RPD group patients and 4375 OPD group patients. The RPD group fared better than the OPD group in terms of estimated blood loss (EBL) (WMD = - 175.65, 95% CI (- 251.85, - 99.44), P < 0.00001), wound infection rate (RR = 0.60, 95% CI (0.44, 0.81), P = 0.001), reoperation rate (RR = 0.61, 95% CI (0.41, 0.91), P = 0.02), hospital day (WMD = - 2.95, 95% CI (- 5.33, - 0.56), P = 0.02), intraoperative blood transfusion (RR = 0.56, 95% CI (0.42, 0.76), P = 0.0001), overall complications (RR = 0.78, 95% CI (0.64, 0.95), P = 0.01), and clinical postoperative pancreatic fistula (POPF) (RR = 0.54, 95% CI (0.41, 0.70), P < 0.0001). In terms of lymph node clearance (WMD = 0.48, 95% CI (- 2.05, 3.02), P = 0.71), R0 rate (RR = 1.05, 95% CI (1.00, 1.11), P = 0.05), postoperative pancreatic fistula (RR = 1, 95% CI (0.85, 1.19), P = 0.97), bile leakage (RR = 0.99, 95% CI (0.54, 1.83), P = 0.98), delayed gastric emptying (DGE) (RR = 0.79, 95% CI (0.60, 1.03), P = 0.08), 90-day mortality (RR = 0.82, 95% CI (0.62, 1.10), P = 0.19), and severe complications (RR = 0.98, 95% CI (0.71, 1.36), P = 0.91), and there were no significant differences between the two groups. Robotic surgery was inferior to open surgery in terms of operational time (WMD = 80.85, 95% CI (16.09, 145.61), P = 0.01). RPD is not inferior to OPD, and it is even more advantageous for EBL, wound infection rate, reoperation rate, hospital stay, intraoperative transfusion, overall complications and clinical POPF. However, these findings need to be further verified by high-quality randomized controlled trials.

Distal pancreatectomy with en bloc celiac axis resection does not improve the R0 rate or median survival time of patients with locally advanced pancreatic cancer: a systematic review and meta-analysis.

BackgroundPancreatic cancer frequently results in celiac artery invasion, resulting in an unresectable disease that generally has a median survival period of 6–11 months. Efforts to achieve curative resection of such tumors have been made by conducting distal pancreatectomy with en bloc celiac axis resection (DP-CAR) in some patients, but the long-term outcome data associated with this approach or its overall value remain to be clarified.MethodsThis meta-analysis was conducted to systematically assess the clinical efficacy of the DP-CAR treatment of unresectable tumors of the pancreatic body or tail (registered with PROSPERO: CRD42019129612). The PubMed, EMBASE, the Cochrane Library, and Web of Science databases were searched to identify relevant retrospective studies pertaining to such treatment.ResultsOverall, 12 retrospective cohort analyses incorporating 213 total DP-CAR cases and 911 DP cases were incorporated into the present meta-analysis. Pooled analyses demonstrated that relative to DP, DP-CAR was related to a longer operative duration [mean difference (MD) −73.69, 95% confidence interval (CI): −112.99 to −34.38, P=0.0002] and higher blood transfusion rates [odds ratio (OR) 0.29, 95% CI: 0.10 to 0.87; P=0.03]. DP-CAR was also linked to increased rates of PV resection (OR 0.17, 95% CI: 0.07 to 0.39; P<0.001) and delayed gastric emptying (DGE) (OR 0.37, 95% CI: 0.15 to 0.93, P=0.03). In contrast, R0 resection rates were higher in the DP group (OR 2.79, 95% CI: 1.90 to 4.09, P<0.001), and these patients also had a significantly improved prognosis (median survival time, 27.0 vs. 17.7 months; P<0.01) relative to the DP-CAR group.ConclusionsThis analysis indicates that DP-CAR is not an effective means of improving R0 rates. However, available studies suggest that it is nonetheless a potentially valuable treatment option for pancreatic cancer patients with celiac axis involvement, and it is associated with a reasonable median survival duration of 17.7 months.

Effect of Billroth-II versus Roux-en-Y reconstruction for gastrojejunostomy after pancreaticoduodenectomy on delayed gastric emptying: A meta-analysis of randomized controlled trials.

Delayed gastric emptying (DGE) is one of the most common complications after pancreaticoduodenectomy (PD). The aim of the present meta-analysis was to evaluate the effect of Billroth-II(B-II) versus Roux-en-Y (R-Y) reconstruction for gastrojejunostomy on DGE after PD. A systematic literature search was performed using the electronic database MEDLINE (via PubMed and OVID), EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) of the Cochrane Library to select pertinent randomized controlled trials (RCTs) on this topic from January 1990 to January 2020. The primary outcome was identified as postoperative DGE. Subgroup analysis was established to compare the incidence of grade B and C DGE. Software Revman 5.3 was used for the statistical analysis, summary statistics were calculated using fixed effect model or random effect model. Five RCTs including a total of 612 patients were eligible for this meta-analysis. The incidence of grade B and C DGE was significantly lower with the B-II reconstruction than with the R-Y reconstruction (8.0% vs. 14.8%, OR=0.49, 95% CI: 0.26-0.95, P=0.03) and the B-II reconstruction took a shorter operation time (WMD=-7.18, 95% CI: [-13.09, -1.27], P=0,02). No statistically significant difference was found between the two reconstruction methods in terms of the incidence of postoperative pancreatic fistula (POPF), bile leak, intra-abdominal abscess, postoperative pneumonia and the length of postoperative hospital stay. B-II reconstruction after PD has a lower incidence of grade B and C DGE and shorter operation time compared with R-Y reconstruction.

Constipation in Patients With Symptoms of Gastroparesis: Analysis of Symptoms and Gastrointestinal Transit

Constipation can be an important symptom in some patients with gastroparesis. The aims were to: 1) Determine prevalence of constipation and delayed colonic transit in patients with symptoms of gastroparesis; 2) Correlate severity of constipation to severity of symptoms of gastroparesis; and 3) Relate severity of constipation to GI transit delays assessed by gastric emptying scintigraphy (GES) and wireless motility capsule (WMC). Patients with symptoms of gastroparesis underwent gastric emptying scintigraphy (GES), wireless motility capsule (WMC) assessing gastric emptying, small bowel transit, and colonic transit, and questionnaires assessing symptoms using a modified Patient Assessment of Upper GI Symptoms [PAGI-SYM] and Rome III functional GI disorder questionnaire. Of 338 patients with symptoms of gastroparesis, 242 (71.5%) had delayed gastric emptying by scintigraphy; 298 (88.2%) also met criteria for functional dyspepsia. Severity of constipation was severe/very severe in 34% patients, moderate in 24%, and none/very mild/mild in 42%. Increasing severity of constipation was associated with increasing symptoms of gastroparesis and presence of irritable bowel syndrome (IBS). Severity of constipation was not associated with gastric retention on GES or WMC. Delayed colonic transit was present in 108 patients (32% of patients). Increasing severity of constipation was associated with increasing small bowel transit time, colonic transit time, and whole gut transit time. Severe/very severe constipation and delayed colon transit occurs in a third of patients with symptoms of gastroparesis. The severity of constipation is associated with severity of gastroparesis symptoms, presence of IBS, small bowel and colon transit delay, but not delay in gastric emptying. ClinicalTrials.gov Identifier: NCT01696747.

Delayed Gastric Emptying Post-Esophagectomy: A Single-Institution Experience.

Delayed gastric emptying (DGE) is a common functional disorder after esophagectomy in patients with esophageal carcinoma. Management of DGE varies widely and it is unclear how comorbidities influence the postoperative course. This study sought to determine factors that influence postoperative DGE. This retrospective study evaluates patients who underwent esophagectomy with gastric pull-up between 2007 and 2019. The cohort was stratified in various ways to determine if postoperative care and outcomes differed, including patient demographics, comorbidities, intraoperative and postoperative procedures. During the study period, 149 patients underwent esophagectomy and 37 had diabetes. Overall incidence of DGE, as defined in this study, was 76.5%. Surgery type was significantly different between DGE and normal emptying cohorts (P = 0.005). Comparing diabetic and nondiabetic patients, there was no significant difference noted in DGE (P = 0.25). Additionally, there was no difference in presence of DGE for patients who underwent any intraoperative pyloric procedure compared to those who did not (P = 0.36). Of significance, all 16 patients with chronic obstructive pulmonary disease had a delay in gastric emptying (P = 0.01). A higher proportion of patients with DGE post-esophagectomy were identified compared to the literature. There is little consensus on a true definition of DGE, but we believe this definition identifies patients suffering in the immediate postoperative period and in follow-up. There is no evidence to support a different postoperative course for patients with diabetes, but the link between chronic obstructive pulmonary disease and DGE warrants further investigation.

S0544 Endoscopic Management of Post-Pancreaticoduodenectomy Delayed Gastric Emptying

INTRODUCTION: Delayed gastric emptying (DGE) is a common cause of post-operative morbidity after pancreaticoduodenectomy (PD). The etiology of DGE is multifactorial and can include disturbances in muscular, hormonal, and neurologic function affecting overall motility. Endoscopic management has been used in patients with refractory DGE at our institution. We aimed to identify those post-PD patients with DGE who underwent endoscopy, characterize their demographics and risk factors, as well as summarize their outcomes. METHODS: This was a single-center retrospective cohort study evaluating patients who underwent PD between 2017 and 2020. Primary endpoints included modified International Study Group on Pancreas Surgery (ISGPS) DGE severity, endoscopic intervention for DGE, and resolution of DGE symptoms following endoscopy as assessed by time to nasogastric tube removal and toleration of full liquid diet. Secondary endpoints included gender, age, presence of diabetes mellitus (DM) (I or II), type of PD (pylorus-preserving versus classic), type of anastomosis, and post-operative day (POD) of initial DGE symptoms. RESULTS: Of the 281 patients reviewed, DGE developed in 55 (19.6%) patients. Of those with DGE, 34 (61.8%), 13 (23.6%), and 8 (14.5%) were categorized as Grade A, B, and C, respectively, with 9 (16.3%) patients requiring endoscopic evaluation (Table 1). Of the 9 patients who underwent endoscopy, the median age was 67.3 (±12.8) years, 5 (55.6%) were men, none had DM, 4 (44.4%) were classified as Grade B, and 5 (55.6%) were classified as Grade C. The median time to onset of DGE symptoms was 4 days, and the median time to endoscopic intervention was 15 days. Only 1/3 of patients required balloon dilation of stricture or angulation during endoscopy, and 7 (77.8%) patients had immediate improvement in DGE symptoms post-endoscopy. CONCLUSION: Endoscopic intervention may play a role in the treatment of patients that are post-PD with Grade B or higher DGE who are refractory to medical therapies. Our data suggests that regardless of the type of PD or whether balloon dilation is performed endoscopically, patients with grade B or higher DGE may benefit from endoscopy and overall have resolution in their symptoms within one day of the procedure.Table 1

EP32 Gastroparesis in Sjögren’s syndrome

EP32 Gastroparesis in Sjögren’s syndrome

S2077 Balloon-Induced Gastric Outlet Obstruction

INTRODUCTION: Intragastric balloons (IGB) function as an artificial bezoar and delay gastric emptying by increasing wall strain and contributing to feelings of satiety. 25% of patients who undergo IGB placement will experience complications, with nausea and vomiting as the most common (8.6%), and obstruction within the digestive tract as a much rarer cause (0.8%). Here we report gastric outlet obstruction (GOO) as a rare complication of IGBs. CASE DESCRIPTION/METHODS: A 67-year-old female with hypothyroidism and major depressive disorder presented with 5 days of profound nausea and vomiting. Prior to admission, the patient underwent gastric balloon placement and after the procedure, the patient was unable to tolerate both solid food and liquids. The patient denied any abdominal pain and her last bowel movement was 2 days prior to admission. Lab work revealed severe hypokalemia (2.6 mmol/L) and hypomagnesemia (< 0.2 mg/dL). CT imaging of the abdomen and pelvis revealed an 11-cm gastric balloon within the distal stomach without signs of bowel obstruction (image 1). The patient immediately underwent esophagogastroduodenoscopy, which revealed the IGB obstructing a large food bolus (image 2). The IGB was subsequently deflated and removed. The patient was discharged home after electrolyte repletion and diet toleration. DISCUSSION: Traditionally, the IGB is a silicone balloon filled with saline that is adjustable in size, safe, and significantly effective in weight loss. Almost half of all gastric balloons are removed early. Indications for gastric balloon removal include severe symptom intolerance, balloon deflation, digestive tract obstruction, and concern for gastric ulcer/perforation. Its risks for serious complications should not be overlooked, as digestive tract obstruction from displaced or deflated balloons may lead to gastric perforation or even death. There is debate regarding the preference for type of fluid or air medium in IGBs. The recently implemented air-filled IGB has also been effective in significant weight loss reduction with lower rates of nausea, vomiting and bowel obstruction compared to fluid-filled IGBs. In this case, this was the second fluid-filled IGB the patient had placed and removed. A different type of IGB could have been considered. With new emerging technology in both endoscopic technique and balloon durability, new studies will need to examine the continued safety and efficacy of gastric balloons in obesity management.Figure 1.: Image 1. CT chest with oral contrast, depicting large saline filled gastric balloon.Figure 2.: Image 2. Left: IGB obstructing antrum from prior EGD; Right: IGB obstructing antrum with food bolus.

A multicenter clinical analysis of short-term efficacy of laparoscopic radical resection of hilar cholangiocarcinoma

Objective: To investigate the feasibility and safety of laparoscopic radical resection of hilar cholangiocarcinoma at multiple centers in China. Methods: Between December 2015 and August 2019, the clinical data of 143 patients who underwent LRHC in Affiliated Hospital of North Sichuan Medical College, Second Hospital of Hebei Medical University, Affiliated Hospital of Xuzhou Medical University, Affiliated Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Hunan Provincial People's Hospital, the First Hospital Affiliated to Army Medical University, Sir Run Run Shaw Hospital Affiliated to Medical College of Zhejiang University, West China Hospital of Sichuan University, Nanfang Hospital of Southern Medical University and the First Affiliated Hospital of Chongqing Medical University were collected prospectively. There were 92 males and 51 females with age of (64±11) years (range: 53 to 72 years). Bismuth type: type I, 38 cases (26.6%), type Ⅱ, 19 cases (13.3%), type Ⅲa, 15 cases (10.5%), type Ⅲb, 28 cases (19.6%) and type Ⅳ, 43 cases (30.0%). The patients within the first 10 operation cases in each operation time (the first 10 patients in each operation team) were divided into group A (77 cases), and the patients after 10 cases in each operation time were classified as group B (66 cases); the cases with more than 10 cases in the center were further divided into group A(1) (116 cases), and the center with less than 10 cases was set as group A(2) (27 cases). T test or Wilcoxon test was used to compare the measurement data between groups, and the chi square test or Fisher exact probability method was used to compare the counting data between groups. Kaplan Meier curve was used for survival analysis. Results: All patients successfully completed laparoscopic procedure. The mean operation time was (421.3±153.4) minutes (range: 159 to 770 minutes), and the intraoperative blood loss was 100 to 1 500 ml (median was 300 ml) .Recent post-operative complications contained bile leakage, abdominal bleeding, abdominal infection, gastrointestinal bleeding, and delay gastric emptying, pulmonary infection, liver failure, et al.The post-operative hospital stay was (15.9±9.2) days. The operation time in group B was relatively reduced ( (429.5±190.7)minutes vs. (492.3±173.1)minutes, t=2.063, P=0.041) and the blood loss (465 ml vs. 200 ml) was also reduced (Z=2.021, P=0.043) than that in group B. The incidence of postoperative biliary fistula and lung infection in patients in group A was significantly higher than that in group B (χ(2)=4.341, 0.007; P=0.037, 0.047) .Compared with group A(2), the operation time in group A(1) was relatively reduced( (416.3±176.5)minutes vs. (498.1±190.4)minutes, t=2.136, P=0.034) , the incidence of bile leakage and abdominal cavity infection in group A(1) was lower than that in group A(2) (χ(2)=7.537, 3.162; P=0.006, 0.046) . Kaplan Meier survival curve showed that the difference of short-term survival time between group A and group B was statistically significant (P<0.05) . Conclusions: The completion of laparoscopic hilar cholangiocarcinoma radical surgery is based on improved surgical skills, and proficiency in standardized operation procedures.It is feasible for laparoscopic radical resection of hilar cholangiocarcinoma to well experienced surgeon with cases be strictly screened, but it is not recommended for widespread promotion at this exploratory stage.

S3427 Cannabis in Relation to Gastroesophageal Reflux Disease

INTRODUCTION: There is a wide distribution of cannabinoid receptors (CBR) in the enteric nervous system, highlighting the role of cannabis in GI health and disease. Of these, CB1 is most often expressed and has been shown to decrease intra-gastric pressure, affect transient LES relaxation (TLESR), and concurrently delay gastric emptying via inhibition of excitatory neurons. We compared three different articles on their studies of cannabinoid receptors in relation to the upper GI tract. The goal of this systematic review is to assess the current knowledge of cannabis implementation, effectiveness, and its adverse side effects, in addition to identifying areas for expanding research. CASE DESCRIPTION/METHODS: In a study conducted by Calabrese et al, 87 total subjects consisting of 10 controls, 39 with non-erosive esophageal reflux (NERD), and 38 with erosive esophageal reflux (ERD) who had typical symptoms for >1 year had eight specimens of macroscopically normal esophageal mucosa taken and analyzed for expression of CBRs. Beaumont et al assessed the response of 10 mg and 20 mg Δ9-THC, a cannabinoid agonist, given three doses each a week apart in healthy volunteers. LES pressure, spontaneous swallows, and reflux episodes were measured. Scarpenllini et al studied the effects of a CB1 receptor antagonist Rimonabant on fasting and postprandial LES function in healthy subjects. Twelve healthy volunteers underwent esophageal manometry studies with administration of wet swallows and a meal after 3 days of premedication with placebo or 20 mg of Rimonabant. Transient LES relaxations and reflux episodes were measured. DISCUSSION: There is a need for more research to be performed, not only on the effects of THC on the GI system, but also for dosing to determine whether or not cannabis can be used as a therapy for esophageal disorders. With increased regulation of cannabis products and further research, consumers would be able to reduce the risks of experiencing unpleasant side effects. It is important to note that cannabis use can also lead to complications, including cannabinoid hyperemesis syndrome. No definitive recommendations can be made at this time on whether or not cannabis use will be a useful therapy for GI disorders until more research is completed.

S1350 Relation of Increased Pyloric Diameter and Distensibility Measured by EndoFLIP to Improved Gastric Emptying After G-POEM for Refractory Gastroparesis

INTRODUCTION: Gastric per-oral endoscopic myotomy (G-POEM) to treat gastroparesis works by decreasing pyloric outlet obstruction. G-POEM is effective in some, but not all patients, suggesting multiple causes of gastric emptying delay. Impedance planimetry with EndoFLIP (Functional Lumen Imaging Probe) measures pyloric function before and after G-POEM. The relation of improvements in pyloric functional parameters to acceleration of gastric emptying after G-POEM is unproven. We compared EndoFLIP measurements of pyloric diameter and distensibility after endoscopic myotomy to normalization of gastric emptying rates in an initial series of patients with refractory gastroparesis who underwent G-POEM. METHODS: 13 patients with refractory gastroparesis underwent gastric emptying scintigraphy before and after G-POEM. Pyloric EndoFLIP was conducted with balloon inflation to 30-50mL. Pre- and post-myotomy mean pyloric diameter and distensibility were compared in those without and with normalization of gastric emptying (< 10% 4 hr scintigraphic retention) performed approximately 3 months after G-POEM. RESULTS: Gastric emptying was normal after G-POEM in 5 patients (4 hr retention 4 ± 4%) and abnormal in 8 patients (4 hr retention 27 ± 23%) (P = 0.05). In the whole group, mean pyloric diameter increased from 13.5 ± 2.1 to 16.2 ± 2.7mm on 40 mL inflation (P < 0.0001) and distensibility increased from 5.1 ± 1.8 to 8.2 ± 4.6mm2/mmHg on 50mL inflation (P = 0.01). Figure 1 shows similar antropyloroduodenal diameters in relation to gastric emptying normalization before and after G-POEM. Increases in pyloric diameter were not different in those with normal vs. abnormal gastric emptying (3.3 ± 1.1 vs. 1.4 ± 1.7mm) (P = 0.25). Figure 2 shows that pre- and post-myotomy pyloric distensibility and increases in distensibility were similar in those with normal vs. abnormal gastric emptying after G-POEM. CONCLUSION: Mean pyloric diameter and distensibility measured by EndoFLIP increased after G-POEM for refractory gastroparesis. These increases were similar in patients who normalized their gastric emptying after myotomy compared to those who did not. This raises the possibility of two gastroparesis subtypes—patients primarily with pyloric dysfunction who respond to G-POEM and those who do not respond who likely have primary antral or fundic impairments. Confirmation of these initial findings will require larger cohorts.Figure 1.: Pre- and post-myotomy antropyloroduodenal diameters measured by EndoFLIP were similar in patients who had normal vs. abnormal gastric emptying after G-POEM.Figure 2.: Distensibility pre- and post-myotomy and net increases in distensibility after myotomy were similar in patients who had normal vs. abnormal gastric emptying after G-POEM.

Is delayed gastric emptying associated with pylorus ring preservation in patients undergoing pancreaticoduodenectomy?

Background/objectiveA high incidence of delayed gastric emptying (DGE) is observed in patients undergoing pylorus-preserving pancreaticoduodenectomy (PpPD). However, DGE incidence after pancreaticoduodenectomy varied because of heterogeneity in surgical techniques, number of surgeons, and DGE definition. This study aimed to evaluate the difference in the incidence of DGE following PpPD and pylorus-resecting pancreaticoduodenectomy (PrPD) and to analyze the risk factor of DGE by a single surgeon to determine whether pylorus preservation was the main factor of DGE. MethodsThis retrospective study included 115 patients who underwent PpPD (with pylorus ring preservation) and PrPD (without pylorus ring preservation) with laparotomy by a single surgeon at a tertiary center. ResultsThe overall incidence of DGE was 23.1%. For comparison, 20 patients (39.2%) in the PpPD group and 5 patients (8.8%) in the PrPD group had DGE, showing a significant difference (p < 0.001). On univariate analysis, hypertension, PpPD, operation time, intraoperative bleeding, packed red blood cell transfusion ≥500 mL, and clinically relevant postoperative pancreatic fistula were associated with DGE. Multivariate analysis identified pylorus preservation and clinically relevant postoperative pancreatic fistula as risk factors for DGE. ConclusionCompared with PpPD, PrPD significantly reduced the incidence of DGE.