Postoperative Motility Disorders Research Articles

Endoscopic management of spontaneous esophageal and postoperative motility disorders

Considerable progress has been made in therapeutic endoscopy over recent years and new techniques now offer access to a new space, the submucosal space, thus paving the way for new therapeutic perspectives, in particular, for functional endoscopy. The first of these applications, POEM (Per-oral endoscopic myotomy), has become, since the beginning of the 2010's, an endoscopic alternative to Heller myotomy for the treatment of achalasia. The results of this technique have been fully documented, and the technique has replaced pneumatic dilatation and become the standard treatment for this indication with equivalent effectiveness compared to traditional surgery, but with less morbidity. Indeed, the overall efficacy is around 90%, results are stable over time, and severe morbidity is less than 1%. Later, other motility disorders, such as spastic disorders, have been treated, certainly with less impressive outcomes than for achalasia, but still, of interest. This approach has also been applied to post-fundoplication motility disorders, whose de novo prevalence can be as high as 20%, and for which management is complex; this represents another new non-surgical perspective. The POEM procedure for this indication, in addition to myotomy, allows performance of a partial incision of the wrap with substantial symptomatic relief. In conclusion, the technique seems to have a bright future as it is progressively applied to more and more motility disorders.

Occurrence of motility disorders in patients undergoing tube surgery-consecutive, retrospective follow-up case series analysis.

The two glaucoma drainage devices (GDD) Ahmed and Baerveldt tubes are most commonly used for the treatment of refractory glaucoma. We noticed a significant number of patients with postoperative motility disorders resulting in diplopia. We investigated the occurrence and patterns of postoperative motility disorders overall and between the two GDD tubes using the Hess Screen Test. Retrospective single-center matched case series of 20 patients undergoing Ahmed and 20 patients undergoing Baerveldt tube implantation with a follow-up of at least 1year. In order to investigate the dynamic of GDD-induced motility disorder over time, from 25 patients, a follow-up examination from two different time periods (3 to 6months and 12 to 24months postoperatively) was available. From these 25 patients, 12 had received an Ahmed and 13 a Baerveldt GDD. To compare the different Hess Screen Tests, we developed nine categories of possible emerging motility disorder in the operated eye as a primary endpoint: Motility restriction in up-gaze, in down-gaze, in abduction, in adduction; combined motility disorders in up-gaze and adduction, up-gaze and abduction, down-gaze and adduction, down-gaze and abduction. If there was no motility disorder, this was also separately classified. Regardless of the used device, Ahmed or Baerveldt, most patients experienced motility disorders to some extent; mainly down-gaze and adduction were affected. However not every motility disorder resulted in diplopia. Although over time a decrease in ocular misalignment was seen, the incidence of diplopia was stable. Nevertheless, only few required therapy. We noted no difference between Ahmed and Baerveldt tube implant devices. Ocular misalignment and restriction of motility is a common finding after GDD. Although not every motility disorder results in diplopia, it is frequent. Therefore, it needs to be taken into consideration in informed consent.

SUPPRESSION OF THE SMALL INTESTINE SHRINKABLE ACTIVITY AFTER USAGE OF THE ANESTHETIC KETAMINE

The work is devoted to the problem of general anesthetics side effects during surgical interventions. In particular, some of the common complications of anesthetics usage are intestinal motility disorders (eg, ileus), nausea and vomiting. We analyzed a clinical data of 60 patients who underwent analgosedation (AS) during coronary artery stenting. They were divided into 2 groups (1 group - AS with Diazepam and Fentanyl, 2 group - AS with Ketamine, Fentanyl and Propofol). Significantly more frequent manifestations of nausea in the perioperative period were identified in the group where ketamine was used. This formed the basis of the study of the molecular and cellular mechanisms of the effects of ketamine on the contractile activity of the smooth muscles of the small intestine.Anesthetics are known to interact with receptors, G-proteins and ion channels, including transient receptor potential channels (TRP channels). The member of this superfamily, TRPC4 channel, which is coupled to muscarinic receptors (M2/M3 type) through G-protein activation and causes cholinergic excitation and contraction of small intestinal smooth muscles, may be a potential target for ketamine.Thus, we aimed to investigate the effects of ketamine (100 μM) on the muscarinic cation current (mICAT), which underlies cholinergic excitation-contraction coupling of visceral smooth muscles. All experiments were performed on single ileal myocytes freshly isolated from the longitudinal layer of the mouse ileum using patch-clamp techniques in the whole-cell configuration. mICAT was recorded using symmetrical Cs+ solutions (containing Cs+125 mM). [Ca2+]i was ‘clamped’ at 100 nM using 10 mM BAPTA/4.6 mM CaCl2 mixture. Measurements of isometric contractile force of the small intestinal smooth muscles were recorded using tensiometry techniques. It was showed that 100 μM ketamine inhibits mICAT . mICAT initiated by the application of CCh (50 μM) was suppressed on 64% (n=5) and mICAT, induced by intracellular GTP γ s (200 μM) that interacts directly with the G-proteins (when muscarinic receptors are bypassed) was inhibited on 42% (n=5). Ketamine inhibited intestinal smooth muscle contractions evoked by carbachol (50 μM) by about 40 % (n=5). Thus, we can conclude that both muscarinic receptors and G-proteins (or their coupling) are affected by ketamine, but the main sites of ketamine action appear to be the G-proteins. These data will provide basis for the molecular mechanisms of postoperative motility disorders and thus may be important for the development of novel approaches to the correction of such states.

1764 It’s Not Always Reflux: The Role of High-Resolution Manometry in Management of Patients With Sleeve Gastrectomy

INTRODUCTION: We present cases of esophageal motility disorders associated with sleeve gastrectomy and identify the role of high-resolution manometry (HRM) in perioperative diagnosis and management. CASE DESCRIPTION/METHODS: Case 1: A 44-year old female with history of morbid obesity and gastric reflux presented with persistent symptoms of regurgitation, vomiting, and refractory reflux after undergoing a sleeve gastrectomy two years prior. Upper endoscopy showed slight resistance to endoscope passage at the lower esophageal sphincter and HRM evaluation was consistent with Type II achalasia, a finding confirmed by barium esophagram. The patient underwent a Heller myotomy with conversion into gastric bypass. On follow-up, patient noted no further recurrence of her presenting symptoms. Case 2: 52-year old female with multiple comorbidities presented with refractory dysphagia. She had undergone sleeve gastrectomy 5 years prior and subsequently developed worsening postprandial chest pain and solid food dysphagia. Outside work up of her dysphagia including multiple endoscopies and an esophagram were negative. On present evaluation, a 13 mm Barium pill traversed the esophagus without delay, and HRM showed a hypercontractile esophagus with high normal integrated relaxation pressure. The patient was started on antispasmodic therapy with symptom improvement. DISCUSSION: Laparoscopic sleeve gastrectomy is a bariatric surgical procedure for rapid weight loss in those classified as morbidly obese. The procedure leaves patients with a narrow tubular stomach roughly the diameter of the esophagus. Post operatively, patients have been noted to experience dysphagia, odynophagia, and most commonly (19.7% of cases) reflux. In our cases, patients experienced severe esophageal dysmotility which may have been caused by post-operative alterations of gastric anatomy and pressures. The mechanism behind post-operative motility disorders is unclear, and some studies have suggested that the procedure may unmask previously latent or subclinical disorders rather than induce them. We believe that HRM should be used as part of high value care in evaluating gastric sleeve patients with esophageal symptoms, especially before surgical revisions. Braghetto, I., et al. OBES SURG (2010) 20: 357. https://doi-org.elibrary.amc.edu/10.1007/s11695-009-0040-3.

Electrical stimulation with motility analysis of five parts of the gastrointestinal tract

Abstract Gastrointestinal (GI) motility disorders are frequent and clinically significant conditions with impairment of patient’s quality of life. Examples range from upper GI symptoms such as dysphagia and gastroparesis to lower GI manifestations, namely chronic-intestinal pseudo obstruction, diarrhea and constipation. Furthermore, postoperative motility disorders are common. Currently, available pharmacological or dietetic treatment options are limited. Since GI motility is based on myoelectric activity, electrical stimulation (ES) is a promising alternative. Numerous studies have demonstrated suitable pacing strategies and parameters in different GI segments. However, results of multilocular ES are rare. We report the first experimental study to evaluate ES of five GI parts in a porcine model. Multi-channel electromyography (EMG) recordings of gastrointestinal baseline and poststimulatory electrical activity were realized together with video-based marker tracking (VBMT). ES provoked visible GI contractions and appeared to modulate frequencies of slow waves and spikes. Further investigations are needed for analysis of locoregional and cross-organ effects of ES on the GI tract.

Influence of drug correction options of postoperative motility disorders of the gastrointestinal tract on inflammatory and anti-inflammatory markers

Introduction. Postoperative dysmotility of the gastrointestinal tract is a common complication after operations on the abdominal cavity. Intestinal inflammatory response plays an important role in the development of postoperative motility disorders. Materials and methods. After Local Ethics Committee approval and obtaining informed consent, 103 patients were prospectively divided into 4 groups depending on the characteristics of post-operative intensive care. In the 1 (control) group (n=27), patients after operation received stimulation of the gastrointestinal tract with metoclopramidum and neostigminum. In group 2 (n=24), patients received L-arginine and metoclopramidum. In the group 3 (n=25) patients received metoclopramidum and simeticonum. In group 4 (n=27), patients received L-arginine, metoclopramidum and simeticonum. Markers of inflammation (leukocyte levels, fibrinogen, IL-1α, TNFα, IL-10, the calculation of leukocyte index of intoxication) were studied preoperatively, after 1,3 and 7 days. Results and Conclusion. Pathological process in the abdomen accompanied by the development of postoperative gastrointestinal dysmotility, increase in the number of white blood cells to 58.8% (p <0.001) and fibrinogen to 55.5% (p<0.001), imbalance of the inflammatory response of the body in the form of increased pro-inflammatory IL-1α by 25.1% (p = 0.047) with a simultaneous decrease the level of TNF more than 400% (p <0,001), before surgery. Group 1 patients inflammatory response persisted for more than 7 days after the operation and leads to depletion of proinflammatory cytokine system, as indicated by the levels of pro-inflammatory IL-1α and TNFα, whose values were below normal at 503% (p <0.001) and 57.9% (p <0.001). When using metoclopramide and L-arginine manifestations of inflammatory response persisted throughout the observation period, but progressively, and at 7 days after operation were smaller than in the other groups. So, in group 2 at 7 days after operation the level of IL-1α was the highest, exceeding the value of 1 to 367% (p <0.001), 3 - by 314% (p <0.001), 4 - 400% (p <0.001). At the same, TNFα levels in group 2 did not differ statistically significantly from preoperative. In group 1 at 7 days after surgery there was increase of anti-inflammatory IL-10 level is above normal and figures 3 and 4 groups at 78.2% (p <0.001) and 124% (p <0.001) and 60, 2% (p = 0.001). The most rapid restoration of peristalsis was using metoclopramide and L-arginine. So, in group 2 independent carminative observed after 2.22 days after operation that 21.8% (p = 0.001) was lower than in group 1, 29.7% (p <0.001) - 3 groups, 26 6% (p = 0.003) - 4 group. This reduces the length of stay in ICU. 100% of patients 3 and 4 and the absolute majority of the patients 1 and 2 groups at 28 days after surgery VIII reached the level of quality of life scale RLAS

Changes of smooth muscle contractile filaments in small bowel atresia

To investigate morphological changes of intestinal smooth muscle contractile fibres in small bowel atresia patients. Resected small bowel specimens from small bowel atresia patients (n = 12) were divided into three sections (proximal, atretic and distal). Standard histology hematoxylin-eosin staining and enzyme immunohistochemistry was performed to visualize smooth muscle contractile markers α-smooth muscle actin (SMA) and desmin using conventional paraffin sections of the proximal and distal bowel. Small bowel from age-matched patients (n = 2) undergoing Meckel's diverticulum resection served as controls. The smooth muscle coat in the proximal bowel of small bowel atresia patients was thickened compared with control tissue, but the distal bowel was unchanged. Expression of smooth muscle contractile fibres SMA and desmin within the proximal bowel was slightly reduced compared with the distal bowel and control tissue. There were no major differences in the architecture of the smooth muscle within the proximal bowel and the distal bowel. The proximal and distal bowel in small bowel atresia patients revealed only minimal differences regarding smooth muscle morphology and the presence of smooth muscle contractile filament markers. Changes in smooth muscle contractile filaments do not appear to play a major role in postoperative motility disorders in small bowel atresia.

Gastrointestinal Motility After Digestive Surgery

Gastrointestinal (GI) motility dysfunction is a common complication of any abdominal surgical procedure. During fasting, the upper GI tract undergoes a cyclic change in motor activity, called the interdigestive migrating motor contraction (IMC). The IMC is divided into four phases, with phase III having the most characteristic activity. After digestive surgery, GI motility dysfunction shows a lack of a fed response, less phase II activity, more frequent phase III activity of the IMC, and some phase III activity migrating orally. Postoperative symptoms have been related to motor disturbances, such as interrupted or retrograde phase III or low postprandial activity. The causes of GI disorder are autonomic nervous dysfunction and GI hormone disruptions. The administration of a motilin agonist can induce earlier phase III contractions in the stomach after pancreatoduodenectomy. For nervous dysfunction, an inhibitory sympathetic reflux is likely to be important in postoperative motility disorders. Until recently, treatment for gut dysmotility has consisted of nasogastric suction, intravenous fluids, and observation; however, more effective treatment methods are being reported. Recent discoveries have the potential to decrease postoperative gut dysmotility remarkably after surgery.

Postoperative ileus: part II (Clinical therapy)

To avoid or reduce postoperative ileus, the operative trauma should be minimized and epidural anesthesia for spinal inhibition of the sympathetic nervous system or i. v. lidocaine should be used, all of which probably act by reducing visceral afferent nerve fiber activity. Recent data suggest that perioperative fluid restriction might reduce postoperative ileus. Epidural anesthesia with local anesthetics and replacing opioids by non-steroidal anti-inflammatory drugs (NSAIDs) for postoperative pain treatment improve the recovery of gastrointestinal motility disturbances. Prior to the operation, the patient should be informed regarding postoperative motility disorders, its length and the presumed resumption of oral food intake, which has been shown to shorten hospital stay. Early postoperative food intake stimulates small and large bowel motility via interenteric reflex arches, avoids i. v. lines and renders discharge acceptable for the patient. Treatment of postoperative ileus includes osmotic laxatives and prokinetic drugs like erythromycine and acetylcholinesterase inhibitors. By combining epidural anesthesia and the sparse use of i. v. opioids with early food intake and, if necessary, laxatives or prokinetics, postoperative ileus should be coped adequately. Nevertheless, the development of new specific prokinetic drugs with minimal or no side effects should remain a target for drug companies to further improve treatment of postoperative ileus.

Preoperative and Postoperative Motility Disorders of the Stomach

Improved technology has expanded the study and understanding of gastrointestinal motility. Although no clear cause and effect relation has been demonstrated, altered motility has been found in association with a variety of nonsurgical and postoperative settings. As this relation is better defined, perhaps patients who are at risk to develop complications of surgery can be better identified so that treatment can be tailored toward their specific defect. Technological advances can also be expected to provide new and more effective interventions in this expanding field.