Gastric Emptying Procedure Research Articles

TRAITEMENT LAPAROSCOPIQUE DE LA STENOSE PYLORO-DUODENALE D’ORIGINE ULCEREUSE AU SERVICE DE CHIRURGIE GENERALE DE L’HOPITAL GENERAL IDRISSA POUYE.

ABSTRACT Introduction: pyloro-duodenal ulcerative stenosis is the most common chronic complication of ulcer disease in developing countries. Its diagnosis calls upon fibroscopy (FOGD) and oeso-gastroduodenal transit (TOGD). The aim of our work was to report our indications and our results in the surgical treatment of ulcerative pyloro-duodenal stenosis by laparoscopic route in the general surgery department of the Idrissa POUYE general hospital. Patients and methods: We conducted a retrospective study (May 2006 to December 2021) of 73 patients with pyloro-duodenal stenosis of ulcerative origin. The surgical approach was an open laparoscopy. The gestures were a bilateral truncal vagotomy (VTB) associated with a gastric emptying procedure. Results: The average age of our patients was 43 years old (range 17 and 87 years old), with a sex ratio of 2.04. We found 52 cases of stenosis at the sthenic phase (71.2%) and 21 cases at the asthenic phase (28.8%). The average duration of evolution of the ulcerous syndrome was 7 months (extreme 3 and 120 months). All the patients had benefited from an esogastroduodenal fibroscopy and an esogastroduodenal transit. The stenosis was complete in 34.2% (n: 25) and incomplete in 65.8% (n: 48). Truncal vagotomy was performed in all patients. It was associated with gastroenteroanastomosis in 93.2% (n: 68) of cases, with pyloroplasty in 6.8% (n: 5) of cases. The average duration of intervention was 92 minutes with extremes of 45 and 107 minutes. Mortality was nil. Morbidity concerned 8.1% of patients (n:6). Functionally, the patients were classified as Visick I (89%, Visick II 7% and Visick III 4%. Conclusion: Surgery for ulcerative pyloroduodenal stenosis is still topical in developing countries. Thus, truncal vagotomy associated with laparoscopic gastric emptying seems to give good functional results with any mortality and low morbidity. Keywords: pyloro-duodenal stenosis; laparoscopy; truncal vagotomy.

Gastroparesis in children.

Gastroparesis is a disorder with delayed gastric emptying in the absence of mechanical obstruction. It is one of the more common dysmotilities that occur in the gastrointestinal tract, and is thought to primarily affect adults. Pediatric cases of gastroparesis were considered rare; however, recent evidence suggests growing recognition in children and adolescents. Therefore, it is important for the pediatric caregiver to understand the condition and the treatment options available. The majority of patients are women, and presentation is usually with symptoms of persistent nausea, emesis, postprandial pain and bloating, and early satiety. Weight loss may occur in some cases, though this is not universal. The majority of cases are idiopathic, with diabetes mellitus the second most common cause. Treatment consists of symptomatic relief with medication to counteract the nausea, emesis, pain, bloating, gastroesophageal reflux, early satiety, and improve gastric emptying. Dietary modification is also used with small meals and avoidance of high fiber and fat-containing foods. Recalcitrant cases of gastroparesis require the use of additional approaches such as jejunal feeds, intrapyloric botulinum toxin, gastric emptying procedures such as pyloroplasty, and gastric electrical stimulation. We will review these options in this article.

Efficacy of Laparoscopic Pyloroplasty for the Treatment of Gastroparesis

The modest results of nonoperative modalities for the treatment of gastroparesis necessitate greater consideration of surgical therapies. However, the role of surgery is not well defined. The aim of this study is to present our experience with laparoscopic pyloroplasty as early treatment for gastroparesis. Fifty patients with refractory gastroparesis underwent laparoscopic pyloroplasty (hand-sewn Heineke-Mikulicz configuration) from 2006 to 2013 at our institution. Preoperative and postoperative symptom data, gastric emptying scintigraphy, and technical outcomes of the procedure were reviewed. A single-factor ANOVA was performed for the comparison of continuous variables. Results are reported as mean ± SD or median absolute deviation. Thirty-four of 50 (68%) patients had previous foregut procedures and/or cholecystectomy. Thirty-two of 50 (64%) patients underwent concomitant procedures (ie, paraesophageal hernia repair and gastrostomy takedown) along with the pyloroplasty. Operative time, including combined procedures, blood loss, and length of stay were 175 ± 56 minutes, 64 ± 50 mL, 2.5 ± 2.7 days, respectively. There were no conversions to open technique or intraoperative complications. There were no suture-line leaks. The readmission rate was 14%. All patients had symptom follow-up and 33 (66%) had postoperative gastric emptying scintigraphy. Postoperative symptom improvement was reported by 82% of the patients (p < 0.001). Median preoperative T1/2 was 180 ± 73 minutes and postoperative T1/2 was 60 ± 23 minutes (p < 0.001). Five patients (10%), who had normalized postoperative T1/2 times, required other gastric emptying procedures; distal gastrectomy (n = 2), duodenojejunostomy (n = 2), and gastric stimulator placement (n = 1). Laparoscopic pyloroplasty is an effective early-treatment modality for selected cases of gastroparesis, with substantial improvement in objective gastric emptying times and low morbidity. The laparoscopic approach does not preclude subsequent procedures when necessary.

Gastric Lavage Guided by Ultrathin Transnasal Esophagogastroduodenoscopy in a Life-threatening Case of Tobacco Extract Poisoning: A Case Report

Nicotine, which is found in tobacco, is one of the most toxic of all known poisons. A 31-year-old woman was brought to our emergency department 2 hours after ingesting a usually fatal dose of a tobacco extract. Although gastric lavage was once commonly used to treat poisoning cases of this type, lavage can lead to such complications as aspiration, hypoxia, oropharyngeal and gastric trauma, and electrolyte disturbances. Recent guidelines have suggested less-aggressive gastric-emptying procedures as initial treatments. Currently, there are no absolute indications for gastric lavage use. The present patient had a history of depressive episodes and had attempted suicide by ingesting an extract derived from 20 cigarettes mixed with alcohol. There was no evidence of vomiting or seizures occurring before arrival of the ambulance. Physical examination revealed no signs of sweating, although the patient appeared to be confused, which is often seen with nicotine intoxication. She admitted using 2 kinds of cigarette, each of which typically contain 11.2 mg of nicotine. The patient's nicotine level was suspected to be higher than 40 to 60 mg, which is normally fatal. To determine whether gastric lavage was indicated in this case, we performed ultrathin transnasal esophagogastroduodenoscopy, which neither requires sedation nor compromises the airways. Although 2 hours had passed since ingestion, the tobacco extract and food were directly visualized within the stomach. Subsequently, gastric lavage was performed with 2,000 mL of water administered through a nasogastric tube. Ultrathin esophagogastroduodenoscopy made it possible to directly observe the gastric lavage and to ensure the stomach contents had been completely removed. No changes were noted in the vital signs, and no obstruction of the airways was observed. The patient recovered quickly and was discharged the following day. Ultrathin esophagogastroduodenoscopy helped determine the diagnosis and ensure that gastric lavage had been performed without complications.

Gastric emptying scans: unnecessary preoperative testing for fundoplications?

Purpose Delayed gastric emptying (DGE) as indicated by preoperative gastric emptying scan (GES) is one rationale for performing a gastric emptying procedure (GEP) at time of fundoplication for gastroesophageal reflux disease (GERD). However, the role of GES and GEP in the surgical management of GERD remains unclear. We examined the use of preoperative GES in fundoplication patients. Methods Retrospective chart review of patients undergoing fundoplication from 2000 to 2005 in a single institution including patient demographics, operative procedure, and postoperative outcomes at 1-year follow-up was analyzed using χ 2 test. Results Of 76 fundoplication patients, 39 (51%) had preoperative GES with 11 patients (28%) having DGE and 16 GEP performed. Developmentally delayed children were more likely to have GES. There were no significant differences in postoperative complications, length of hospital stay, or use of anti-GERD medications at 1 year between patients who had preoperative GES and those who did not. In the developmentally delayed group, there were no differences in outcomes between those with preoperative GES and those who did not. Conclusions There were no differences in outcomes for GERD patients with or without preoperative GES or GEP postfundoplication. The use of GES in the management of GERD requires further evaluation.

European multicenter survey on the laparoscopic treatment of gastroesophageal reflux in patients aged less than 12 months with supraesophageal symptoms

This multicenter survey includes neonates and infants who underwent surgery for primary gastroesophageal reflux (GER) who presented with supraesophageal symptoms of unknown origin with a minimum of 12 months postoperative follow-up. A total of 726 patients underwent GER surgery in 10 European Centers in the period 1998-2002. Respiratory symptoms were present in 204 patients (28%); 135 patients (17%) had surgery under 1 year of age, and 46 of them (6.3%) because of respiratory symptoms. Surgery was performed without any previous medical treatment in 10 cases (21%). The type of procedure included 37 complete 360 degrees wraps (80%) (Nissen, 12, and Rossetti, 25) and nine partial wraps (20%) (Thal five, Lortat Jacob one, Toupet one, others two). Gastrostomy was associated in 17 cases (37%) (6 PEG and 11 modified Stamm). No gastric emptying procedures were recorded. No major intraoperative complications were reported. Six patients developed complications (13%) and a redo operation was performed in three (6.5%). Respiratory outcome after antireflux surgery was good in 35 patients (76%) and fair with significantly improved respiratory symptoms in 11 (24%). This multicenter survey underlines that GER has to be suspected and aggressively treated in infants with difficult-to-treat supraesophageal symptoms, and also in high-risk cases, in order to prevent major complications.

Minimally Invasive Surgical Techniques in Reoperative Surgery for Gastroesophageal Reflux Disease in Infants and Children

Fundoplication is commonly performed in children suffering from complications of gastroesophageal reflux disease (GERD). Recently laparoscopic fundoplication has become a standard of care for GERD in children. Published reports show that 2.3 to 14 per cent of children require reoperation after failed fundoplication. The purpose of this study is to show the feasibility of minimally invasive surgical (MIS) techniques to treat children after failed fundoplication. A retrospective chart review was performed for all patients who underwent laparoscopic redo fundoplication at Children's Healthcare of Atlanta at Egleston from July 1998 to July 2000. The patients' records were reviewed for age, diagnosis, type and time of initial operation, type and time of redo operation, operative time for redo operation, and complications. Seventeen children (age 3 months to 18 years) had operations for failed fundoplication attempted using MIS techniques. Six of these children were referred after their initial operation performed elsewhere. Nine (53%) were neurologically impaired. Ten (59%) have respiratory complications of GERD. The initial procedures were as follows: One open Nissen fundoplication, two open Thal fundoplications, 13 laparoscopic Nissen fundoplications, and one laparoscopic Toupet fundoplication. The reoperative procedures performed were revision of fundoplication and hiatal hernia repair (13) or hiatal hernia repair only (four). Two patients had concurrent gastric emptying procedures. One procedure was converted to open for technical reasons. One patient developed a pelvic abscess secondary to leakage around the gastrostomy tube. One child had erosion into the esophagus of a Dacron patch that was used to close a large hiatal defect. Thirteen patients began feeding by the first postoperative day. We conclude that MIS techniques can be applied to reoperative surgery for the treatment of GERD with an acceptable complication rate in this difficult group of patients. Reoperative patients appear to have the same benefits from MIS as patients undergoing their initial procedure.

A prospective evaluation of dietary status and symptoms after near-total esophagectomy without gastric emptying procedure

Background: After esophagectomy, the stomach is the most commonly utilized reconstructive conduit. There remains debate among surgeons regarding the requirements for pyloroplasty/pyloromyotomy following reconstruction. We present a series of patients having undergone near total esophagectomy and reconstruction with gastric tube without gastric emptying procedure to analyze critically these patients’ ability to reestablish a subjectively acceptable and nutritionally adequate eating pattern without significant side effects of early satiety, dumping, or diarrhea. Methods: Between 1991 and 1998, 48 patients underwent esophagectomy utilizing this technique and were available for long-term follow-up and nutritional assessment. Patient weights were recorded at 2 weeks, 6 months, and 1 year and a telephone interview conducted at a mean of 36 months postoperatively for the evaluation of eating patterns and symptoms. A subgroup of these patients (32 of 48) completed a 3-day dietary record that was assessed by a certified nutritionist. This patient group included 10 patients (21%) who had received perioperative chemoradiotherapy. Results: Dietary intake was characterized as normal or minimally limited in 41 patients (85%). Those who had received perioperative chemoradiotherapy needed no significant increased time to return to a normal dietary baseline (6.1 versus 5.9 months). Mean weight loss prior to surgery was 3 kg. Weight loss continued for the first 6 months (mean 10 kg); however, 63% were able to gain weight from 6 months to 1 year following surgery (mean 3 kg). Most patients were overweight prior to operation (mean 115% of ideal body weight) and achieved a new postoperative baseline (mean 104% of ideal body weight) at 1 year. Patients demonstrated a mean daily caloric intake of 2,179 kilocalories per day, which was 98% of recommended according to their ideal body weight. Postoperative symptoms of short-term nausea (19%), occasional dysphagia with certain foods (38%), mild increased stool frequency (15%), and occasional regurgitation (25%) were noted. Conclusions: Near-total esophagectomy with verticalized gastric tube without a gastric emptying procedure is well tolerated and allows a return to subjectively acceptable and nutritionally appropriate dietary eating pattern without significant associated side effects.

Antireflux surgery in children under 3 months of age

Purpose: The aim of this study was to analyze the indications and results of fundoplication in 110 infants under 3 months of age. Methods: A retrospective review was conducted on the charts of all infants operated on for gastroesophageal reflux disease (GERD) at the UCLA Medical Center from January 1980 to December 1997. There were 59 boys and 51 girls. Recurrent emesis was the indication for operation in 62 of 110 infants, and respiratory symptoms in 85 of 110, with 54 of 110 having both. Neurological impairment was present in 32%. Prematurity was present in 21%; 35% had associated anomalies. Overall, 81 of 110 infants (73.6%) had one or more associated major malformations or disorders. Reflux was confirmed by upper gastrointestinal series findings in 63 of 78, esophageal pH monitoring in 60 of 62, and endoscopy in five of seven. Results: Mean age at operation was 1.8 ± 0.1 months and mean weight was 3,686 ± 90.2 g. A Nissen fundoplication was performed on 104 children, and six underwent a Thal procedure. Thirty-one had a gastric emptying procedure for delayed gastric emptying. Complications occurred in 7 infants. Emesis was controlled in 57 of 62 patients, aspiration in 38 of 48, and apneic spells in 54 of 57. Follow-up greater than 6 months was available for 73 patients. There were nine late deaths, all related to severe associated malformations. Seven patients required a redo fundoplication for recurrent reflux. Conclusions: Nissen fundoplication can be performed safely in symptomatic infants under 3 months of age with low mortality and morbidity rates and with resolution of the presenting symptoms in 79% of infants.

Gastric emptying procedures decrease the risk of postoperative recurrent reflux in children with delayed gastric emptying

Purpose: Although several centers often perform gastric emptying procedures (GEP) together with fundoplication for gastroesophageal reflux (GER) and delayed gastric emptying (DGE), the benefit of GEP is controversial. The present study addresses the question of whether adding a GEP in children with preoperatively diagnosed GER and DGE affects the recurrence rate of GER after Nissen fundoplication (NF). Methods: A retrospective chart review was performed on all children under the age of 16 years, operated on for GER from 1980 to 1997, who had a preoperative diagnosis of DGE, and at least 6 months of follow-up. Gastric retention of more than 50% of a radiolabeled meal at 90 minutes was considered DGE. Recurrent reflux was defined as reappearance of GER symptoms, confirmed by postoperative esophagram or 24 hours of pH monitoring. Results: Of the 183 patients with DGE, 92 were available for long-term follow-up. Of these, 20 had no gastric emptying procedure performed (no-GEP group) and 72 had a GEP performed together with an NF (GEP group). Groups were comparable as to age at operation, mean follow-up time, male to female ratio and prevalence of associated anomalies. A higher prevalence of neurological impairment (NI) was present in the GEP group (48.6% v 20.0%). Mean preoperative gastric retention was significantly higher in the GEP group (69.9 ± 1.3%) than in the no-GEP group (61.4 ± 2.2%). No complications resulted from the GEP. Recurrent reflux rate was 18.1% in the GEP group (13 of 72) versus 35.0% (7 of 20) in the no-GEP group. Actuarial analysis disclosed a marginally significant difference in the rate of recurrent reflux between the groups ( P = .057) and estimation of the relative risk showed a 1.94 increase of recurrent reflux risk in the no-GEP (0.89 < RR < 4.20). Conclusions: Children with DGE, who did not have GEP, had twice the frequency of recurrent reflux as those who had a GEP. Preoperative screening for DGE, as well as operative correction of DGE at the time of fundoplication, is therefore recommended.

Surgical treatment of gastroesophageal reflux in children: a combined hospital study of 7467 patients.

To review retrospectively the combined clinical experience with the surgical treatment of persistently symptomatic gastroesophageal reflux (SGER) in childhood from seven large children's surgery centers in the United States. During the past 20 years, 7467 children <18 years of age underwent antireflux operations for SGER at the seven participating hospitals. Fifty-six percent were neurologically normal (NN) and 44% were neurologically impaired (NI). The most frequent diagnostic studies were upper gastrointestinal series (68%), esophageal pH monitoring (54%), gastric emptying study (32%), and esophagoscopy (25%). The age at operation was under 12 months in 40% and 1 to 10 years in 48%. The type of fundoplication was Nissen (64%), Thal (34%), and Toupet (1.5%). A gastric emptying procedure was performed on 11.5% of NN patients and 40% of NI patients. Laparoscopic fundoplication was performed on 2.6% of patients. Good to excellent results were achieved in 95% of NN and 84.6% of NI patients. Major complications occurred in 4.2% of NN and 12.8% of NI patients. The most frequent complications were recurrent reflux attributable to wrap disruption (7.1%), respiratory (4.4%), gas bloat (3.6%), and intestinal obstruction (2.6%). Postoperative death occurred in 0.07% of NN and 0.8% of NI patients. Reoperation was performed in 3.6% of NN and 11.8% of NI patients. The results and complications were similar among the participating hospitals and did not seem related to the type of fundoplication used. The excellent results (94% cure) and low morbidity with gastroesophageal fundoplication with or without a gastric emptying procedure from a large combined hospital study indicate that operation should be used early for SGER in NN children and to facilitate enteral feedings and care in NI children.

A comparison of the efficacy of pyloromyotomy and pyloroplasty in patients with gastroesophageal reflux and delayed gastric emptying

Purpose: Delayed gastric emptying (DGE) in children with gastroesophageal reflux (GER) is often treated with a gastric emptying procedure. Although pyloroplasty is the most common gastric emptying procedure performed, pyloromyotomy is easier to perform and is associated with less morbidity. The aim of this study was to compare the efficacy of pyloromyotomy and pyloroplasty in children with DGE and GER undergoing a fundoplication. Materials and Methods: We reviewed the charts of 54 patients with DGE who underwent pyloromyotomy (n = 29), or pyloroplasty (n = 25) along with a fundoplication. A technetium 99-labeled sulfur colloid liquid-phase gastric emptying study (GES) was performed in the pre-and early postoperative period (within 6 months after operation). Normal stomach emptying was defined as greater than 40% at 1 hour. Comparisons were made with regard to postoperative complication rate, incidence of redo fundoplication, length of postoperative hospital stay, and pre- and postoperative GES. Results: The pyloroplasty and pyloromyotomy group were comparable in terms of age, sex, operative indications, and neurological status. There was no significant difference in the GES between the two groups preoperatively. There was a trend toward a decreased incidence of early postoperative complications including gas bloat, wound infection, pneumonia, dysphagia, bowel obstruction and dumping syndrome in the pyloromyotomy (8, 28%) when compared with the pyloroplasty group (12, 48%, P = .10). The mean postoperative hospital stay was 10.6 ± 1.4 days for the pyloroplasty group and 7.6 ± 1.0 days for the pyloromyotomy group ( P + .08). The incidence of a redo fundoplication was 8% in the pyloroplasty and 7% in the pyloromyotomy group. Postoperative gastric emptying increased significantly in both groups (pyloroplasty group, from 18.1 ± 3.1 to 49.5 ± 7.9%, P = .0005; pyloromyotomy group, from 19.3 ± 2.1 to 41.2 ± 3.7%, P = .0001). There was no significant difference in the postoperative GES between the two groups ( P = .289). Conclusion: Both pyloroplasty and pyloromyotomy performed in conjunction with a fundoplication resulted in a significant increase in early postoperative gastric emptying. There was no advantage of pyloroplasty over pyloromyotomy during this follow-up period. These data suggest that pyloromyotomy is an effective gastric emptying procedure in children with GER and DGE.

Drug overdose — reducing the load

To review available information about various methods for reducing gastrointestinal absorption of a poison or drug. Articles on overdose and accidental poisoning generated by the Australian Medlars Service and concentrating on the period between 1985 and 1990 were surveyed. Earlier studies were included if relevant. English language articles with an emphasis on studies using objective methods to measure individual and comparative efficacy of gastrointestinal decontamination techniques were selected. A total of 65 articles were reviewed. Gastric emptying procedures (gastric lavage or emesis caused by syrup of ipecac) are only effective if performed within one hour of drug ingestion. Gastric lavage is superior to syrup of ipecac. Oral administration of activated charcoal is more effective than either gastric emptying procedure, and is recommended for most cases of poisoning. Cathartics (sorbitol) can be used with activated charcoal. Whole bowel lavage with polyethylene glycol is indicated in selected cases of potentially lethal overdose where the toxic substance cannot be absorbed by charcoal and has passed the pylorus. Children--syrup of ipecac can be given at home to children older than 12 months. Most children who reach hospital can be treated by charcoal alone. ADULTS--Most patients are managed with supportive care and, in the absence of contraindications, a single dose of activated charcoal if seen within four hours of ingestion of the poison or drug. Gastric lavage is used if the patient presents within one hour of ingestion and has clinical features of toxicity.

Gastric Emptying Procedures in the Self-Poisoned Patient: Are we Forcing Gastric Content beyond the Pylorus?

A prospective, randomized, single-blind study was carried out to determine whether gastric content is forced into the small bowel when gastric-emptying procedures are employed in self-poisoned patients. They were asked to swallow barium-impregnated polythene pellets, immediately prior to either gastric lavage or ipecacuanha-induced emesis. A second group of patients, who did not require treatment, were used as controls. Sixty patients were recruited to the study. The data show a significant difference in the number of residual pellets in the small bowel of the treated group (n = 40), when compared with the control group (P less than 0.0001). There was no statistical difference in the number of pellets in the small bowel when the treated groups were compared with each other. In addition, the inefficiency of gastric-emptying procedures is highlighted; 58.5% of the total number of pellets ingested were retained in the gastrointestinal tract of the ipecacuanha-treated group, while 51.8% of total pellets ingested were retained in the gastric lavage-treated group.

Prospective evaluation of gastric emptying in the self-poisoned patient

The authors prospectively studied the effect of gastric emptying (GE) and activated charcoal (AC) upon clinical outcome in acutely self-poisoned patients. Presumed overdose patients (n = 808) were treated using an alternate day protocol based on a 10-question cognitive function examination and presenting vital sign parameters. Asymptomatic patients (n = 451) did not receive GE. AC was administered to asymptomatic patients only on even days. GE in the remaining symptomatic patients (n = 357) was performed only on even days. On emptying days, alert patients had ipecac-induced emesis while obtunded patients received gastric lavage. AC therapy followed gastric emptying. On nonemptying days, symptomatic patients were treated only with AC. No clinical deterioration occurred in the asymptomatic patients treated without GE. AC use did not alter outcome measures in asymptomatic patients. GE procedures in symptomatic patients did not significantly alter the length of stay in the emergency department, mean length of time intubated, or mean length of stay in the intensive care unit. Gastric lavage was associated with a higher prevalence of medical intensive care unit admissions ( P = .0001) and aspiration pneumonia ( P = .0001). The data support the management of selected acute overdose patients without GE and fail to show a benefit from AC in asymptomatic overdose patients.

Incidental Detection of Esophageal Diverticulum During Gastric Emptying Examination

The majority of diverticula of the middle and lower esophagus are asymptomatic and usually detected on an upper gastrointestinal series performed for other indications. A case of esophageal diverticulum, first detected during a nuclear gastric emptying procedure in which persistent retention of activity was noted in the mid-esophagus, is reported. Esophageal diverticulum was confirmed on an upper gastrointestinal series. This serendipitous scintigraphic finding during a gastric emptying study is not believed to have been reported previously. The diagnosis of esophageal diverticulum should be considered when persistent retention of activity is noted in the esophagus.

Gastric emptying of liquid meals: validation of the gamma camera technique.

In order to assess the extent of errors and to provide correction factors for gamma camera gastric emptying studies of liquid meals labelled with radionuclides (99Tcm or 113Inm), a series of phantom studies were performed with different gastric emptying procedures, gamma cameras and data handling systems. To validate the overall accuracy of the method, 24 combined aspiration and gamma camera gastric emptying studies were carried out in three normal volunteers. Gastric meal volume, expressed as a percentage of the original volume of the meal ingested was underestimated due to scattered radiation from the stomach. The underestimation was 7-20% varying with the size of the gastric region of interest (ROI), the energy of the nuclide and the fraction of meal in the stomach. The overestimation, due to scattered radiation from the gut, was negligible (1-3%) for any of the procedures with 10% of the meal situated outside the stomach at a distance of at least 1 cm. Sections of the duodenal loop were always inside the stomach ROI and were likely to contain a constant fraction of the meal (3-10%). The gamma camera technique eliminated much of the error due to variations of stomach geometry and produced accurate quantitative gastric emptying data comparable to those obtained by evacuation (P greater than 0.10), when the entire field maximum 1-min count achieved within the first 20 min of a study was taken as representing the original volume of the meal ingested, and when corrections for area related errors due to scattered radiation from the stomach were performed.

Whole bowel irrigation as a gastrointestinal decontamination procedure after acute poisoning.

Assuming a stable or stabilised patient, preventing the absorption of ingested toxins becomes a primary objective in the treatment of acute overdose. Traditional interventions aimed at achieving this end include ipecac-induced emesis, large bore orogastric lavage and activated charcoal administration (Cupit & Temple 1984; Easom & Lovejoy 1979). Whether any of these procedures benefits the patient remains unknown. Induced emesis and gastric lavage have especially been questioned (Comstock et al. 1981; Corby et al. 1968; Fane et al. 1971; Neuvonen et al. 1983; Tenenbein 1985a; Vale et al. 1986) and the literature seems to favour activated charcoal administration without a gastric emptying procedure (Chin 1972; Curtis et al. 1984; Fane et al. 1971; Kulig et al. 1985; Tenenbein et al. 1987a). However, the most common practice is to use one of the gastric emptying procedures, followed by activated charcoal. Apart from the concerns about their effectiveness, situations arise where all 3 of these interventions can be expected to be of limited benefit to the poisoned patient. These include the ingestion of a very large amount of a toxic substance (e.g. many times the lethal dose) , late presentation after the overdose, ingestion of delayed release pharmaceuticals and ingestion of substances not adsorbed by activated charcoal (particularly iron). In these situations whole bowel irrigation with polyethylene glycol electrolyte lavage solution offers promise as a method of treatment. The purpose of this article is to review relevant data and experience regarding this technique.

Management of acutely poisoned patients without gastric emptying

During an 18-month period, 592 acute oral drug overdose patients were studied prospectively in a controlled, randomized fashion to determine the efficacy of gastric emptying procedures in altering clinical outcome. Patients presenting on even-numbered days had no gastric emptying procedures performed, and they were compared to patients presenting on odd-numbered days who received either syrup of ipecac or gastric lavage. Patients were carefully followed for evidence of subsequent clinical improvement or deterioration after initial management. Syrup of ipecac did not significantly alter the clinical outcome of patients who were awake and alert on presentation to the emergency department (ED). Gastric lavage in obtunded patients led to a more satisfactory clinical outcome (P less than .05) only if performed within one hour of ingestion. Gastric emptying procedures in the ED for initial treatment of drug overdose are generally not of benefit unless gastric lavage is performed within one hour of ingestion in obtunded patients.

Inefficacy of gastric emptying procedures

Gastric lavage or ipecac-induced emesis are routinely recommended in the management of the acutely poisoned patient. Efficacy of either procedure has not been shown. Three cases are described clearly demonstrating inefficacy of emesis and wide bore orogastric lavage. The role of these procedures requires careful controlled evaluation. Until the publication of supportive data, their efficacy is unproven.