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Zhonghua Wai Ke Za Zhi [Chinese Journal... May 2024To investigate pertinent risk factors for postoperative pancreatic fistula(POPF) after robotic-assisted distal pancreatectomy(RDP). This is a retrospective cohort...
To investigate pertinent risk factors for postoperative pancreatic fistula(POPF) after robotic-assisted distal pancreatectomy(RDP). This is a retrospective cohort study. Clinical data of 1 211 patients who underwent various methods of distal pancreatectomy at the Department of General Surgery,Ruijin Hospital,Shanghai Jiaotong University School of Medicine,between January 2021 and December 2023 were retrospectively collected. Among the study participants,440 cases were in the robot-assisted group(173 males and 267 females),with an age((IQR)) of 55(29)years;720 cases were in the open surgery group (390 males and 330 females),with an age of 64(15)years;and 51 cases were in the laparoscopic group(17 males and 34 females),with an age of 56(25)years. These 440 patients who underwent RDP were divided into two cohorts based on the presence of clinically relevant pancreatic fistulas(grades B and C). Univariate and multivariate analysis were performed on 27 factors related to POPF. Univariate analysis methods included independent sample -test,Mann-Whitney test,and test,while multivariate analysis utilized binary logistic regression. After stratification by pathological type,there was no significant difference in the incidence of pancreatic fistula between the robot-assisted group and the open surgery group(benign tumor:=1.200,=0.952;malignant tumor:=0.391,=0.532). The surgical duration of the RDP group (=15.113,<0.01; =4.232, <0.01) was significantly shorter than that of the open surgery and laparoscopic groups,so as the intraoperative blood loss (=12.530,<0.01;=2.550,=0.032). Postoperative hospital stay in the RDP group was significantly shorter than that in the open surgery group (=10.947, <0.01), but not different from that in the laparoscopic group (>0.05). All 440 patients underwent successful surgery,of which there was only 1 case who underwent a conversion to open surgery. A total of 104 patients(23.6%) developed clinically relevant pancreatic fistulas,and no perioperative mortality was observed. Univariate analysis revealed that 6 factors were associated with POPF after RDP: gender(=12.048,=0.001),history of smoking (=6.327,=0.012),history of alcohol consumption (=17.597,<0.01),manual pancreas division (=9.839,=0.002),early elevation of amylase in drainage fluid (=5.187,<0.01),and delayed gastric emptying (=4.485,=0.034). No statistically significant association with POPF was found for the remaining factors(all >0.05).The cut-off value for the early amylase level in the drainage fluid was determined to be 7 719.5 IU/ml,with an area under curve of 0.676 determined by receiver operating characteristic curve analysis. Binary logistic regression analysis identified a history of alcohol consumption(=0.002,95%:0.112 to 0.623),manual pancreas division(=0.001,95%:1.446 to 4.082),early amylase level of drainage fluid ≥7 719.5 IU/ml(<0.01,95%:0.151 to 0.438),and delayed gastric emptying(=0.020,95%:1.131 to 4.233) as independent risk factors for POPF of RDP. Patients with pancreatic body and tail tumors who receive RDP therapy are at increased risk of developing a pancreatic fistula if they have a history of alcohol consumption,manual pancreas division,early elevation of amylase in drainage fluid to ≥7 719.5 IU/ml, or delayed gastric emptying.
PubMed: 38808435
DOI: 10.3760/cma.j.cn112139-20240325-00144 -
Zhonghua Wai Ke Za Zhi [Chinese Journal... May 2024To compare the perioperative outcomes of laparoscopic duodenal-preserving pancreatic head resection(LDPPHR) with laparoscopic pancreaticoduodenectomy(LPD) in the...
To compare the perioperative outcomes of laparoscopic duodenal-preserving pancreatic head resection(LDPPHR) with laparoscopic pancreaticoduodenectomy(LPD) in the treatment of borderline and benign diseases of the pancreatic head. This is a retrospective cohort study. Perioperative data from 87 patients with non-malignant pancreatic head diseases who underwent LDPPHR or LPD were retrospectively collected in the Department of Biliary-Pancreatic Surgery,Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from January 2020 to December 2022. There were 49 male and 38 female patients with an age of 57.0(16.5) years (range: 20 to 75 years). Forty patients underwent LDPPHR and 47 patients underwent LPD. Quantitative data following a normal distribution were compared using Student's -test, while quantitative data not following a normal distribution were compared using the Mann-Whitney test. Comparisons of categorical or ordinal variables were made using test or Fisher's exact test. Logistic regression analysis was used to estimate the risk factors associated with the rate of complications. There were no statistically significant differences between the LDPPHR group and the LPD group in terms of reoperation rate,total hospital stay duration,postoperative hospital stay duration,90-day mortality rate,30-day and 90-day readmission rates,and 2-year tumor recurrence rate (all >0.05). The complication rate was higher in the LDPPHR group compared to the LPD group(32 cases (80.0%) 24 cases (51.1%),=7.89,=0.005),but there was no difference in the rate of Clavien-Dindo classification of surgical complications≥Ⅲ between the two groups(4 cases (10.0%) 6 cases (12.8%), <0.01, =0.947). Additionally,the rate of delayed gastric emptying (DGE) was higher in the LDPPHR group compared to the LPD group (=10.79,=0.001),but there was no statistically significant difference in the rate of B,C grade DGE between the two groups (=0.48, =0.487). There were no statistically significant differences in the rates of postoperative pancreatic fistula,bile leakage,post-pancreatectomy hemorrhage,intra-abdominal infection,and pulmonary infection between the two groups (all >0.05). The results of the univariate logistic regression analysis showed that LDPPHR (compared to LPD, =3.83, 95%: 1.46 to 10.04, =2.73,=0.006) and preoperative biliary stent placement (compared to non-use of biliary stent, =5.30, 95%: 1.13 to 25.00, =2.11, =0.035) were risk factors for the complication rate,but neither was an independent risk factor for complication rate (all >0.05). The preliminary results suggest that LDPPHR can achieve perioperative safety and effectiveness comparable to LPD.
PubMed: 38808434
DOI: 10.3760/cma.j.cn112139-20240317-00130 -
World Journal of Clinical Cases May 2024Gastroesophageal reflux disease (GERD) is a common complication of esophageal cancer surgery that can affect quality of life and increase the risk of esophageal...
BACKGROUND
Gastroesophageal reflux disease (GERD) is a common complication of esophageal cancer surgery that can affect quality of life and increase the risk of esophageal stricture and anastomotic leakage. Wendan Decoction (WDD) is a traditional Chinese herbal formula used to treat various gastrointestinal disorders, such as gastritis, functional dyspepsia, and irritable bowel syndrome. Mosapride, a prokinetic agent, functions as a selective 5-hydroxytryptamine 4 agonist, enhancing gastrointestinal motility.
AIM
To evaluate the therapeutic effects of WDD combined with mosapride on GERD after esophageal cancer surgery.
METHODS
Eighty patients with GERD were randomly divided into treatment (receiving WDD combined with mosapride) and control (receiving mosapride alone) groups. The treatment was conducted from January 2021 to January 2023. The primary outcome was improved GERD symptoms as measured using the reflux disease questionnaire (RDQ). The secondary outcomes were improved esophageal motility (measured using esophageal manometry), gastric emptying (measured using gastric scintigraphy), and quality of life [measured the Short Form-36 (SF-36) Health Survey].
RESULTS
The treatment group showed a notably reduced RDQ score and improved esophageal motility parameters, such as lower esophageal sphincter pressure, peristaltic amplitude, and peristaltic velocity compared to the control group. The treatment group showed significantly higher gastric emptying rates and SF-36 scores (in both physical and mental domains) compared to the control group. No serious adverse effects were observed in either group.
CONCLUSION
WDD combined with mosapride is an effective and safe therapy for GERD after esophageal cancer surgery. It can improve GERD symptoms, esophageal motility, gastric emptying, and the quality of life of patients. Further studies with larger sample sizes and longer follow-up periods are required to confirm these findings.
PubMed: 38808341
DOI: 10.12998/wjcc.v12.i13.2194 -
Frontiers in Physiology 2024Gastrointestinal motility symptoms may be closely related to thyroid diseases. Sometimes, such symptoms are the only thyroid disease-related clue although the degree of... (Review)
Review
Gastrointestinal motility symptoms may be closely related to thyroid diseases. Sometimes, such symptoms are the only thyroid disease-related clue although the degree of the symptoms may vary. The exact mechanism of action of thyroid hormones on gastrointestinal motility is not completely understood, however, a clue lies in the fact that muscle cell receptors can be directly acted upon by thyroxines. Both hypo- and hyperthyroidism can cause impairment of gastrointestinal motility, modifying structure and function of pharynx and esophagus, and regulating esophageal peristalsis through neuro-humoral interaction. In hyperthyroid patients, alterations of postprandial and basic electric rhythms have been observed at gastro-duodenal level, often resulting in slower gastric emptying. Gastric emptying may also be delayed in hypothyroidism, but an unrelated gastric mucosa-affecting chronic modification may also cause such pattern. Hyperthyroidism commonly show malabsorption and diarrhoea, while hypothyroidism frequently show constipation. In summary, it can be stated that symptoms of gastrointestinal motility dysfunction can be related to thyroid diseases, affecting any of the gastrointestinal segment. Clinically, the typical thyroid disease manifestations may be missing, borderline, or concealed because of intercurrent sicknesses. Motility-linked gastrointestinal problems may easily conceal a misdetected, underlying dysthyroidism that should be carefully analyzed. Here, we aim to elaborate on the associations between thyroid disorders and GI dysmotility and the common clinical manifestations associated with GI dysmotility.
PubMed: 38803365
DOI: 10.3389/fphys.2024.1389113 -
Neurogastroenterology and Motility May 2024The association between upper gastrointestinal symptoms and delayed gastric emptying (GE) shows conflicting results. This study aimed to assess whether the symptoms of...
BACKGROUND
The association between upper gastrointestinal symptoms and delayed gastric emptying (GE) shows conflicting results. This study aimed to assess whether the symptoms of the Gastroparesis Cardinal Symptom Index (GCSI) and/or the scores were associated with the result of GE tests and whether they could predict delayed GE.
METHODS
Patients referred for suspected gastroparesis (GP) were included in a prospective database. Demographical data, medical history, and symptoms of the GCSI score were collected for each patient. A GE scintigraphy was then performed with a 4-hour recording. Delayed GE was defined as a retention rate ≥ 10% at 4 h.
RESULTS
Among 243 patients included in this study, 110 patients (45%) had delayed GE. The mean age (49.9 vs. 41.3 years; p < 0.001) and weight loss (9.4 kg vs. 5.6 kg; p = 0.025) were significantly higher in patients with delayed GE. Patients with diabetes or a history of surgery had a higher prevalence of delayed GE (60% and 78%, respectively) than patients without comorbidity (17%; p < 0.001). The GCSI score was higher in patients with delayed GE (3.06 vs. 2.80; p = 0.045), but no threshold was clinically relevant to discriminate between patients with normal and delayed GE. Only vomiting severity was significantly higher in patients with delayed GE (2.19 vs. 1.57; p = 0.01).
CONCLUSION
GE testing should be considered when there are symptoms such as a higher weight loss, comorbidities (diabetes, and history of surgery associated with GP), and the presence of vomiting. Other symptoms and the GCSI score are not useful in predicting delayed GE.
PubMed: 38798079
DOI: 10.1111/nmo.14821 -
Surgery May 2024Minimally invasive surgery has gained momentum for left pancreatic resections. However, debate remains about whether it has any advantage over open surgery for distal...
BACKGROUND
Minimally invasive surgery has gained momentum for left pancreatic resections. However, debate remains about whether it has any advantage over open surgery for distal pancreatectomy for pancreatic neuroendocrine tumors.
METHODS
This retrospective review examined pancreatectomies performed for resectable pancreatic neuroendocrine tumors at 21 centers in France between January 2014 and December 2018. Short and long-term outcomes were compared before and after propensity score matching based on tumor size, sex, age, body mass index, center, and method of pancreatic transection.
RESULTS
During the period study, 274 patients underwent left pancreatic resection for pancreatic neuroendocrine tumors [109 underwent distal splenopancreatectomy, and 165 underwent spleen-preserving distal pancreatectomy [(splenic vessel preservation (n = 97; 58.7%)/splenic vessel resection (n = 68; 41.3%)]. Before propensity score matching, minimally invasive surgery was associated with a lower rate of major morbidity (P = .004), lower rate of postoperative delayed gastric emptying (P = .04), and higher rate of "textbook" outcomes (P = .04). After propensity score matching, there were 2 groups of 54 patients (n = 30 distal splenopancreatectomy; n = 78 spleen-preserving distal pancreatectomy). Minimally invasive surgery was associated with less blood loss (P = .05), decreased rate of major morbidity (6% vs. 24%; P = .02), less delayed gastric emptying (P = .05) despite similar rates of postoperative fistula, hemorrhage, and reoperation (P > .05). The 5-year overall survival (79% vs. 75%; P = .74) and recurrence-free survival (10% vs 17%; P = .39) were similar.
CONCLUSION
Minimally invasive surgery for left pancreatic resection can be safely proposed for patients with resectable left pancreatic neuroendocrine tumors. Minimally invasive surgery decreases the rate of major complications while providing comparable long-term oncologic outcomes.
PubMed: 38797604
DOI: 10.1016/j.surg.2024.04.005 -
European Journal of Pharmaceutics and... Jul 2024Mathematical models that treat the fed stomach content as a uniform entity emptied with a constant rate may not suffice to explain pharmacokinetic profiles recorded in... (Randomized Controlled Trial)
Randomized Controlled Trial
Drug dissolution and transit in a heterogenous gastric chyme after fed administration: Semi-mechanistic modeling and simulations for an immediate-release and orodispersible tablets containing a poorly soluble drug.
Mathematical models that treat the fed stomach content as a uniform entity emptied with a constant rate may not suffice to explain pharmacokinetic profiles recorded in clinical trials. In reality, phenomena such as the Magenstrasse or chyme areas of different pH and viscosity, play an important role in the intragastric drug dissolution and its transfer to the intestine. In this study, we investigated the data gathered in the bioequivalence trial between an immediate-release tablet (Reference) and an orally dispersible tablet (Test) with a poorly soluble weak base drug administered with or without water after a high-fat high-calorie breakfast. Maximum concentrations (C) were significantly greater after administering the Reference product than the Test tablets, despite similar in vitro dissolution profiles. To explain this difference, we constructed a novel semi-mechanistic IVIVP model including a heterogeneous gastric chyme. The drug dissolution in vivo was modeled from the in vitro experiments in biorelevant media simulating gastric and intestinal fluids in the fed state (FEDGAS and FeSSIF). The key novelty of the model was separating the stomach contents into two compartments: isolated chyme (the viscous food content) that carries the drug slowly, and aq_chyme open for rapid Magenstrasse-like routes of drug transit. Drug distribution between these two compartments was both formulation- and administration-dependent, and recognized the respective drug fractions from the clinical pharmacokinetic data. The model's assumption about the nonuniform mixing of the API with the chyme, influencing differential drug dissolution and transit kinetics, led to simulating plasma concentration profiles that reflected well the variability observed in the clinical trial. The model indicated that, after administration, the Reference product mixes to a greater extent with aq_chyme, where the released drug dissolves better and transfers faster to the intestine. In conclusion, this novel approach underlines that diverse gastric emptying of different oral dosage forms may significantly impact pharmacokinetics and affect the outcomes of bioequivalence trials.
Topics: Humans; Tablets; Drug Liberation; Solubility; Administration, Oral; Therapeutic Equivalency; Gastric Emptying; Models, Biological; Male; Adult; Gastrointestinal Transit; Gastrointestinal Contents; Viscosity; Hydrogen-Ion Concentration; Stomach; Computer Simulation; Young Adult; Gastric Mucosa; Cross-Over Studies
PubMed: 38795785
DOI: 10.1016/j.ejpb.2024.114341 -
Life (Basel, Switzerland) Apr 2024Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have...
BACKGROUND AND AIMS
Pancreaticoduodenectomy (PD) is a complex and high-skill demanding procedure often associated with significant morbidity and mortality. However, the results have improved over the past two decades. However, there is a paucity of research concerning the learning curve for PD. Our aim was to report the outcomes of 100 consecutive PDs representing a single surgeon's learning curve and to depict the factors that influenced the learning process.
METHODS
We reviewed the first 121 PDs performed at our academic center (2013-2019) by a single surgeon; 110 were PDs (5 laparoscopic and 105 open) and 11 were total PDs (1 laparoscopic and 10 open). Subsequent statistics was performed on the first 100 PDs, with attention paid to the learning curve and survival rate at 5 years. The data were analyzed comparing the first 50 cases (Group 1) to the last 50 cases (Group 2).
RESULTS
The most frequent histopathological tumor type was pancreatic ductal adenocarcinoma (50%). A total of 39% of patients had preoperative biliary drainage and 45% presented with positive biliary cultures. The preferred reconstruction technique included pancreaticogastrostomy (99%), in situ hepaticojejunostomy (70%), and precolic gastro-jejunal anastomosis (88%). Postoperative complications included biliary fistula (1%), pancreatic fistula (8%), pancreatic stump bleeding (4%), and delayed gastric emptying (13%). The mean operative time decreased after the first 50 cases ( < 0.001) and blood loss after 60 cases ( = 0.046). R1 resections lowered after 25 cases ( = 0.025). Vascular resections (17%) did not influence the rate of complications ( = 0.8). The survival rate at 5 years for pancreatic adenocarcinoma was 32.93%.
CONCLUSIONS
Outcomes improve as surgeon experience increases, with proper training being the most important factor for minimizing the impact of the learning curve over the postoperative complications. Analyzing the learning curve from the perspective of a single surgeon is mandatory for accurate statistical results and interpretation.
PubMed: 38792572
DOI: 10.3390/life14050549 -
Scientific Reports May 2024Reliable in-vitro digestion models that are able to successfully replicate the conditions found in the human gastrointestinal tract are key to assess the fate and...
Reliable in-vitro digestion models that are able to successfully replicate the conditions found in the human gastrointestinal tract are key to assess the fate and efficiency of new formulations aimed for oral consumption. However, current in-vitro models either lack the capability to replicate crucial dynamics of digestion or require large volumes of sample/reagents, which can be scarce when working with nanomaterials under development. Here, we propose a miniaturised digestion system, a digestion-chip, based on incubation chambers integrated on a polymethylmethacrylate device. The digestion-chip incorporates key dynamic features of human digestion, such as gradual acidification and gradual addition of enzymes and simulated fluids in the gastric phase, and controlled gastric emptying, while maintaining low complexity and using small volumes of sample and reagents. In addition, the new approach integrates real-time automated closed-loop control of two key parameters, pH and temperature, during the two main phases of digestion (gastric and intestinal) with an accuracy down to ± 0.1 °C and ± 0.2 pH points. The experimental results demonstrate that the digestion-chip successfully replicates the gold standard static digestion INFOGEST protocol and that the semi-dynamic digestion kinetics can be reliably fitted to a first kinetic order model. These devices can be easily adapted to dynamic features in an automated, sensorised, and inexpensive platform and will enable reliable, low-cost and efficient assessment of the bioaccessibility of new and expensive drugs, bioactive ingredients or nanoengineered materials aimed for oral consumption, thereby avoiding unnecessary animal testing.
Topics: Humans; Digestion; Hydrogen-Ion Concentration; Models, Biological; Kinetics; Gastrointestinal Tract; Temperature; Miniaturization; Lab-On-A-Chip Devices
PubMed: 38789470
DOI: 10.1038/s41598-024-54612-w -
Surgery May 2024The absence of surgical complications has traditionally been used to define successful recovery after pancreas surgery. However, patient-reported outcome measures as...
BACKGROUND
The absence of surgical complications has traditionally been used to define successful recovery after pancreas surgery. However, patient-reported outcome measures as metrics of a challenging recovery may be superior to objective morbidity. This study aims to evaluate the use of patient-reported outcomes in assessing recovery after pancreas surgery.
METHODS
Patients scheduled for pancreatoduodenectomy were prospectively enrolled between 2016 to 2018. Patient-reported outcomes were collected using the linear analog self-assessment questionnaire preoperatively and on postoperative days 2, 7, 14, 30, and monthly until 6 months. Patients were also asked if they felt fully recovered at 30 days and 6 months. Thirty-day surgical morbidity was prospectively assessed, and the comprehensive complication index at 30 days was used to categorize morbidity as major or multiple minor complications (comprehensive complication index ≥26.2) vs uncomplicated (comprehensive complication index <26.2). Clinically significant International Study Group Pancreas Surgery Grade B and C pancreatic fistulas and delayed gastric emptying were reported. χ and Kruskal-Wallis tests were used to assess associations with recovery by 6 months and quality of life throughout the postoperative period.
RESULTS
Of 116 patients who met inclusion criteria and were enrolled, 32 (28%) had major or multiple minor complications (comprehensive complication index ≥26.2). Overall, fewer than 1 in 10 patients (7%) reported feeling fully recovered at 30 days postoperatively, whereas 55% reported feeling fully recovered at 6 months. Of patients suffering major morbidity, 62% did not recover by 6 months, whereas 38% of those in the uncomplicated group reported not being recovered at 6 months (P = .03). Patients who experienced delayed gastric emptying reported low quality-of-life scores at 1 month (P = .04) compared to those with no delayed gastric emptying, but this did not persist at 6 months (P = .80). Postoperative pancreatic fistula was not associated with quality of life at 1 or 6 months (both P > .05). In the uncomplicated patients, age, sex, surgical approach, and cancer status were not associated with failed recovery at 6 months (all P > .05), and healthier patients (American Society of Anesthesiologists 1-2) were less likely to report complete recovery (42% vs 69% American Society of Anesthesiologists 3-4, P = .04). With the exception of higher preoperative pain scores (mean 2.3 [standard deviation 2.4] among patients not fully recovered at 6 months vs 1.6 [2.2] among those fully recovered, P = .04), preoperative patient-reported outcomes were not associated with failed recovery at 6 months (all P > .05). However, lower 30-day quality of life, social activity, pain, and fatigue scores were associated with incomplete recovery at 6 months.
CONCLUSION
More than 1 in 3 patients with an uncomplicated course do not feel fully recovered from pancreas surgery at 6 months; the presence of surgical complications did not universally correspond with recovery failure. In patients with complications, delayed gastric emptying appears to drive quality of life more significantly than postoperative pancreatic fistula. In patients with uncomplicated recovery, healthier patients were less likely to report full recovery at 6 months. Thirty-day patient-reported outcomes may be able to identify patients who are at risk of incomplete long-term recovery.
PubMed: 38777657
DOI: 10.1016/j.surg.2024.04.002