Intact Pylorus Research Articles

2175 Endoscopic Salvage Repair: Complicated Gastric Sleeve Leak

INTRODUCTION: Gastric leaks following laparoscopic sleeve gastrectomy (LSG) are a feared complication, occurring in 2.4 % of cases in the proximal portion ( >90%). LSG is more prone to a leak due to a long staple line and high intraluminal pressure, sealed between an intact pylorus and lower esophageal sphincter and less likely to close spontaneously. There are no standardized guidelines for management of this or other forms of anastomotic leaks. We present a case that failed to respond to initial attempt to close with a luminal stenting, which led to multiple techniques to include endoscopic vacuum therapy (EVT), pneumatic dilation of the sleeve, and pylori Botox injection that ultimately achieved success. CASE DESCRIPTION/METHODS: 51 year old female with a recent history of laparoscopic sleeve gastrectomy complicated by a proximal leak detected 4 weeks post op. She initially underwent endoscopic closure with an Ovesco placement over the defect of the sleeve leak and stent placement across the sleeve. UGI immediately following the procedure revealed no leak. Subsequent imaging two weeks following the procedure revealed a leak, requiring the stent removal. The endoscopic exam revealed a large proximal sleeve defect leading to a large purulent cavity (3 × 4 cm) with multiple sinus openings. She underwent endoscopic vacuum therapy (14 sessions) every 3-4 days, leading to the complete sealing of the cavity and reduction of the cavity. There was a 1 × 1 cm persistent sealed cavity with diffuse granulation tissue, requiring a placement of a double pigtail stent. After functional stenosis was noted under fluoroscopy, not allowing contrast to freely flow downstream, Botox injection of the pylorus and pneumatic dilation of the sleeve (to 30 mm, 3 sessions) were performed, to relieve the pressure gradient. UGI series confirmed the completely sealed nature of the cavity and smooth contrast flow distally to the small intestine. Pigtail stent was left indefinitely to allow natural healing. DISCUSSION: Multiple endoscopic techniques have been implemented to close LSG leaks. The new paradigm has focused on optimizing pressure gradients to allow internal drainage with closure of the cavity by secondary intention. Our case described an initial failed closure that ultimately achieved success with a variety of techniques to include internal drain placement and Botox and dilation. This subject would benefit from further study to determine optimal initial or stepwise approach.

Comparison of pyloromyotomy, pyloric buginage, and intact pylorus on gastric drainage in gastric pull-up surgery after esophagectomy.

Background:There are controversies regarding the usefulness of the pyloric drainage methods after esophagectomy as well as differences among various pyloric drainage techniques. Therefore, we compared the outcome of pyloromyotomy, pylorus buginage, and no intervention methods on gastric emptying among patients undergone esophagectomy.Materials and Methods:In this randomized clinical trial, patients with diagnosed esophageal cancer or any other benign lesions candidate for esophagectomy were selected. They randomized in three groups with three different approaches for gastric pull-up esophageal surgery including esophagectomy with pyloromyotomy, esophagectomy without intervention, and esophagectomy with pylorus buginage. The outcomes of procedures regarding gastric emptying time and delayed gastric emptying were compared.Results:Thirty patients were allocated in three groups. Gastric emptying time was not significantly different in the three groups (P > 0.05). Frequency of delayed gastric emptying, complications and barium leakage were not different in three studied groups (P > 0.05).Conclusion:Gastric emptying time and delayed gastric emptying were not different between common pyloric drainage methods after esophagectomy and esophagectomy without drainage.

The influence of an intact pylorus on postprandial enteroglucagon and neurotensin release after upper gastric surgery.

Upper partial gastrectomy for carcinoma of the gastric cardia or fundus is unavoidably accompanied by truncal vagotomy, so it is orthodox practice to carry out pyloroplasty with this procedure. In order to assess the effect of leaving an intact pylorus in this operation, 21 patients were investigated with an oral hypertonic load (200 ml 50 per cent glucose solution), and blood was taken at intervals during the test, for the ileal gut hormones, enteroglucagon and neurotensin, as well as for measurements of haematocrit and blood glucose. Clinical features of dumping during the test were sought. There were 7 patients with upper partial gastrectomy, truncal vagotomy and an intact pylorus, 7 patients without a pylorus (total or near total gastrectomy) and 7 patients not subjected to gastric surgery. No significant difference was found in any of the measurements between gastrectomy patients with an intact pylorus and those draining through an enterostomy. However, both these groups differed significantly from normal controls in having greater rates of rise and higher peak values of enteroglucagon, neurotensin, haematocrit and blood glucose, together with a more frequent occurrence of dumping symptoms during the test. As the above measurements probably reflect transit of glucose into the small intestine, the findings in this study suggest that leaving an intact unstenosed pylorus is unlikely to lead to gastric stasis following upper partial gastrectomy.

The value of preserving the pylorus in the surgery of duodenal ulcer.

Abstract Highly selective vagotomy without a drainage procedure (H.S.V.) has been use in the surgical treatment of 120 cases of duodenal ulcer in Leeds over the past 3 years. In this operation preservation of the vagal nerve-supply to the antral region of the stomach permits preservation of an intact pylorus. In the present paper the results which have been achieved are assessed, both clinically and experimentally, by comparison with the results in patients after truncal or selective vagotomy and pyloroplasty at a comparable stage after operation. Studies of gastric emptying provide no evidence of gastric stasis after H.S.V., and symptoms of flatulence and food vomiting are found no more frequently than after vagotomy and pyloroplasty. After both truncal and selective vagotomy and pyloroplasty gastric emptying and small-bowel transit were abnormally fast, whereas after H.S.V. there was much less departure from the values found in preoperative ulcer patients. At the clinical and experimental level dumping and diarrhoea were singnificantly less frequent after H.S.V. than after vagotomy and pyloroplasty. To date there has been no operative mortality, no case of recurrent ulcer, and no reoperation for gastric stasis after H.S.V. Preservation of a more normal pattern of gastric emptying, by reducing the incidence of dumping, diarrhoea, and bile vomiting, has led to better overall (Visick) results after H.S.V. than after truncal or selective vagotomy and pyloroplasty.

Efferent pathways in the reflex control of gastric emptying in rats

Previous studies have established that acid, hypertonic, or protein-rich liquid test meals delay gastric emptying by reflex pathways involving the extrinsic innervation of the gut. To characterize the efferent pathways involved in these reflexes, we have studied the emptying of liquid test meals in control rats and in rats after celiac ganglionectomy, pyloroplasty, and treatment with guanethidine or 6-hydroxydopamine, and in rats with circulating vasoactive intestinal polypeptide (VIP) antibodies. The results suggest that the action of hypertonic solutions on gastric emptying requires an intact celiac ganglion, that acid requires an intact pylorus, and that the action of protein-rich meals is suppressed by VIP antibodies. Sympathetic adrenergic neurons do not apparently mediate the gastric emptying of any of these solutions. The results suggest that there are at least three different reflexes by which the different components of a mixed meal might control gastric emptying. The results are also consistent with the idea that vagovagal reflexes mediate the action of protein-rich solutions on gastric emptying in rats.

Modulation of posttranslational processing of gastrin precursor in dogs

The precursor of the acid-stimulating hormone gastrin is processed in pyloric antral gastrin cells by steps involving sulfation, phosphorylation, cleavage, and amidation. We describe here changes in posttranslational processing in dogs with a surgically excluded antrum; in the preparation we used there was an intact pylorus but antral mucosa was excluded from the normal influence of the luminal contents. Three to five months after the operation, basal plasma gastrin increased from 30.1 +/- 4.0 to 66.1 +/- 16.1 pmol/l, and concentrations of gastrin in the excluded mucosa were 9.23 +/- 1.75 compared with 3.2 +/- 0.56 nmol/g in control antral mucosa. Calculations based on the metabolic clearance rate and plasma and tissue gastrin concentrations suggest two-fold lower fractional release rates from the excluded G-cells compared with normal G-cells. Radioimmunoassay of tissue extracts using antisera specific for the extreme COOH-terminus of progastrin, for glycine-extended G-17, and for the COOH-terminus of G-17, combined with gel filtration and ion exchange chromatography, indicated normal endopeptidase cleavage of progastrin. However there was significantly reduced phosphorylation of the COOH-terminal tryptic fragment of progastrin, and there was also decreased conversion of Gly-extended intermediates to the biologically active COOH-terminally amidated forms of gastrin. Thus, in spite of hypergastrinaemia, the excluded antral mucosa showed evidence of decreased secretory rates associated with decreased progastrin phosphorylation and amidating enzyme activity. The results suggest that contact of antral mucosa with the luminal contents is able to modulate the posttranslational processing of progastrin and so determine the production of biologically active hormone.

Changes in intragastric bile acid composition in patients receiving cimetidine postoperatively

Enterogastric reflux has been implicated as a possible etiologic mechanism in gastritis both after partial gastrectomy and in those with an intact pylorus. We studied the effects of cimetidine on bile acid concentration and composition by high-performance liquid chromatography. The gastric aspirates collected for this study came from 27 prospectively randomized patients receiving intravenous cimetidine (200 mg every 6 hours) and 25 patients given a placebo. Total bile acid concentration of aspirates was determined spectrophotometrically. Marked differences were noted in conjugated bile acids. Glycochenodeoxycholic acid, a toxic dihydroxy bile acid, was decreased after cimetidine compared with results from the placebo. The ratio of less toxic trihydroxylated to more toxic dihydroxylated bile acids was significantly increased. Enterogastric reflux itself seemed unaltered by cimetidine; likewise, the concentration of total bile acids in the cimetidine group was similar to that among patients receiving placebo. These changes in bile salt composition with cimetidine may help explain its salutary effects in gastritis, over and above its ability to reduce gastric hydrogen ion secretion.

Properties of the feline pyloric sphincter in vitro

The purpose of this study was to determine the intrinsic functions of the feline pylorus in vitro. The myoelectric and pressure characteristics of the intact pylorus, antrum, and duodenum, free of extrinsic hormonal or neural influences, were studied in an in vitro bath that allowed separation of the bathing medium surrounding the different bowel segments. Basal recordings revealed a zone of tonic high pressure of 28.4 ± 3.5 mmHg (mean ± SEM) at the pylorus. The basal slow wave frequencies in the pylorus and duodenum were 2.8 ± 1.4 and 12.6 ± 0.6 cycles/min, respectively. Spontaneous action potential-associated phasic contractions of the pylorus were noted in 38% of preparations. Enteric nerve stimulation with direct electric current (10 Hz, 1 ms, 10–50 V) applied proximal to the pylorus gave relaxation of the pylorus at the lower voltages and rebound excitation at higher voltages. Electrical stimulation distal to the pylorus yielded phasic contractile pyloric response during the entire stimulus. The duodenal instillation of 0.5 N HCl produced action potential-associated phasic contractions of the pylorus and duodenum but not the antrum. Pyloric responses to electrical stimulation or acidification were abolished by tetrodotoxin (10−5 M). Bethanechol (10−6 M) or substance P (10−7 M) produced a contractile response at the site of stimulation but this response was not transmitted to include adjacent bowel segments. These studies suggest that the pyloric sphincter with its intrinsic reflex properties can be studied in vitro.

Effects of 15(R)-15-Methyl Prostaglandin E2 (Arbaprostil) on Gastric Secretion and Various Gastric Lesions Induced in Rats

We studied the effects of 15(R)-15-methyl prostaglandin E2 (arbaprostil) on gastric secretion and various acute and chronic gastric lesions produced in rats. Arbaprostil significantly inhibited gastric secretion in 4 hr-pylorus-ligated preparations when given intraduodenally in a dose of 30 or 100 μg/kg. The agent, however, significantly stimulated gastric secretion of rats with either a ligated or intact pylorus when given orally in doses of 3–100 μg/kg. Orally administered arbaprostil dose-dependently prevented the development of HCl-ethanol-, histamine-, water-immersion stress-, or indomethacin-induced gastric erosions. Intraduodenally administered arbaprostil also dose-dependently prevented the development of aspirin-induced gastric erosions in pylorus-ligated rats. Arbaprostil, given orally in doses of 1–100 μg/kg twice daily for 2 weeks, had little or no effect on the healing of acetic acid-induced gastric ulcers. However, oral administration of the agent in a dose of 3 or 10 μg/kg twice daily for 4 weeks significantly accelerated the healing of acetic acid-induced gastric ulcers. The increase in doses up to 100 ¿¿g/kg twice daily for 4 weeks had no effect on ulcer healing. These results indicate that arbaprostil, at either antisecretory or even acid stimulating doses, is effective in preventing the development of acute gastric erosions and in accelerating the healing of chronic gastric ulcers.

Effect of a transpyloric tube on gastric emptying and duodenogastric reflux in the dog.

The effect of a transpyloric tube on duodenogastric reflux and on gastric emptying was studied in dogs with either an intact pylorus, a Heineke-Mikulicz pyloroplasty, or an extramucosal circular pylorectomy. In fasting dogs, duodenogastric reflux was 10 times smaller than after feeding a liquid lipid meal. A transpyloric tube increased the reflux rate in fasting, but not in fed dogs, while pylorectomy increased reflux rate and intragastric accumulation of a duodenal marker in fed, but not in fasting dogs. It is concluded, therefore, that in the dog (1) methods to measure duodenogastric reflux should not involve the necessity to position a transpyloric tube and (2) the pylorus and adjacent structures are involved in keeping duodenogastric reflux at a low level.

Effects of cholestyramine and synthetic hydrotalcite on acute gastric or intestinal lesion formation in rats and dogs.

Cholestyramine, a bile-binding agent, markedly inhibited the development of gastric lesions induced by water-immersion stress in rats and of gastric and intestinal lesions induced by indomethacin in rats and dogs with an intact pylorus. However, cholestyramine had no effect on gastric lesions induced by stress in pylorus-ligated rats and on aspirin-induced gastric lesions in rats and dogs with or without pylorus ligation. Hydrotalcite, a potent antacid, significantly inhibited the gastric lesions induced by stress and aspirin in rats and dogs with or without pylorus ligation. Hydrotalcite also inhibited the gastric lesions induced by a single administration of indomethacin in rats with an intact pylorus. In contrast, the agent had no effect on gastric and intestinal lesions induced by repeated administration of indomethacin to rats and dogs with an intact pylorus. These results suggest that while bile probably plays an important role in the pathogenesis of stress-induced gastric lesions and of indomethacin-induced gastric and intestinal lesions, bile does not appear to play a role in the pathogenesis of aspirin-induced gastric lesions.

Effects of N-acetyl-L-carnosine aluminum (CL-1700) on various acute gastric lesions and gastric secretion in rats.

Effects of a newly synthesized compound, N-acetyl-L-carnosine aluminum (CL-1700), on the formation of various types of acute gastric lesions were studied in rats. CL-1700 at 300 or 1,000 mg/kg (p.o.) significantly inhibited Shay ulcers and water-immersion stress- and aspirin-induced erosions in pylorus-ligated rats, and indomethacin- or phenylbutazone-induced erosions. CL-1700 had a weak effect on water-immersion stress-induced erosions in rats with an intact pylorus. CL-1700 at 100 or 300 mg/kg (i.p.) significantly inhibited Shay ulcers and water-immersion stress-induced erosions in rats with an intact pylorus. However, this compound (i.p.) had no effect on aspirin- and indomethacin-induced gastric erosions. CL-1700 at 1,000 mg/kg (i.d.) significantly reduced the gastric acid output in pylorus-ligated rats but at 300 or 1,000 mg/kg (p.o.) increased the volume, pepsin output and raised the pH value. The effects of CL-1700 on experimental gastric lesions were slightly weaker than those of aluminum sucrose sulfate but almost equal to or better than those of cimetidine. However, the effects of CL-1700 were much more potent than those of gefarnate. As CL-1700 appears to be a promising new anti-gastric lesion agent, the mechanisms of action are now under investigation.

EFFECTS OF N-ACETYL-L-CARNOSINE ALUMINUM (CL-1700) ON VARIOUS ACUTE GASTRIC LESIONS AND GASTRIC SECRETION IN RATS

AbstractEffects of a newly synthesized compound, N-acetyl-L-carnosine aluminum (CL-1700), on the formation of various types of acute gastric lesions were studied in rats. CL-1700 at 300 or 1,000 mg/kg (p.o.) significantly inhibited Shay ulcers and water-immersion stress- and aspirin-induced erosions in pylorus-ligated rats, and indomethacin- or phenyl-butazone-induced erosions. CL-1700 had a weak effect on water-immersion stress-induced erosions in rats with an intact pylorus. CL-1700 at 100 or 300 mg/kg (i.p.) significantly inhibited Shay ulcers and water-immersion stress-induced erosions in rats with an intact pylorus. However, this compound (i.p.) had no effect on aspirin- and indomethacin-induced gastric erosions. CL-1700 at 1,000 mg/kg (i.d.) significantly reduced the gastric acid output in pylorus-ligated rats but at 300 or 1,000 mg/kg (p.o.) increased the volume, pepsin output and raised the pH value. The effects of CL-1700 on experimental gastric lesions were slightly weaker than those of aluminum sucrose sulfate but almost equal to or better than those of Cimetidine. However, the effects of CL-1700 were much more potent than those of gefarnate. As CL-1700 appears to be a promising new anti-gastric lesion agent, the mechanisms of action are now under investigation.

Relative role of pyloroplasty size, truncal vagotomy, and milk meal volume in canine gastric emptying.

The gastric emptying of 10, 20, or 40 ml/kg body mass milk meals was measured before and after Heineke-Mikulicz pyloroplasty of 3, 5, or 7 cm (6 dogs) or truncal vagotomy (3 dogs). The pyloroplasty group then underwent vagotomy, following which the tests were repeated. Initial gastric emptying (in the first 10 min) was increased after 5-and 7-cm pyloroplasties (P<0.01) and particularly after vagotomy with all sizes of pyloroplasty (P=0.001). Regardless of the volume of meal used, after vagotomy and pyloroplasty there was a 51–63% decrease in intragastric volume within the first 10 min. Increased duodenogastric reflux occurred in those dogs who showed rapid initial gastric emptying. After the first 10 min all groups were shown to have virtually normal gastric emptying, except the truncal vagotomy group in which gastric emptying was delayed (P<0.05). It is the combination of pyloroplasty with vagotomy which is required to produce the very rapid initial gastric emptying of a liquid meal following vagotomy with pyloroplasty. It is concluded that two mechanisms control the gastric emptying of a milk meal. The first acts quickly, is dependent on an intact pylorus, and is influenced by the intragastric volume; the second is a more slowly acting mechanism, requiring up to 10 min to have its effect, and is not dependent on an intact pylorus or the intragastric volume. After vagotomy and pyloroplasty, the speed of gastric emptying in the first 10 min is proportional to the original meal volume, and therefore the therapy of postvagotomy diarrhea and dumping with small frequent meals seems rational.