Functional delayed gastric emptying (FDGE) refers to the delayed gastric emptying caused by non-mechanical obstruction secondary to gastric surgery, also known as gastroparesis. It is a relatively rare recent complication after gastric surgery and is easily misdiagnosed as mechanical obstruction of the anastomosis or output collaterals. The correct and timely diagnosis and treatment of FDGE is important to avoid blind reoperation and reduce patient pain. From January 1998 to December 2003, 224 cases of gastric surgery for peptic ulcer disease were performed in our hospital, and 9 cases of FDGE occurred.
Clinical manifestations
Most of the FDGE patients’ symptoms appeared from 3 to 10 days after surgery, with an average of 7.2 days. It occurred when gastrointestinal function was gradually restored, gastrointestinal decompression was stopped, and a liquid diet or a change from a liquid diet to a semi-liquid diet was eaten. In two cases, a large amount of gastric juice was still drawn out from the gastric tube on the 3rd to 7th postoperative day, both of which were greater than 1000 ml/d. After clamping the gastric tube, epigastric fullness, nausea and vomiting occurred.
In 4 cases, the gastric tube was removed 4 to 7 days after surgery, and epigastric fullness, nausea and vomiting appeared 1 to 2 days after eating a liquid diet. 3 cases showed epigastric fullness, nausea and vomiting after changing from liquid to semi-liquid on the 8th to 10th day after surgery. Examination revealed light pressure pain in the epigastrium, positive vibrohydraulic sound, slightly weak or normal bowel sounds, and no air over water sound. All cases were found to have no peristaltic movement of the residual stomach by iodine hydrography after the onset of symptoms, and the contrast agent did not pass through the anastomosis. Gastroscopic examination of the anastomosis had different degrees of congestion and edema, and the gastroscope could smoothly pass through the anastomosis into the duodenum or jejunum, and the residual stomach had no peristalsis or only weak peristalsis.
Treatment and results
The treatment measures included fasting and water fasting, continuous gastrointestinal decompression, and gastric lavage with warm saline. Water and electrolyte balance was maintained, and fluids, ions and trace elements were replenished. Nutritional support, intermittent blood and plasma transfusion. Gastric motility drugs were applied to enhance gastrointestinal motility, and acid suppressants were administered to reduce gastric juice secretion. In this group, 8 cases recovered and 1 case died after comprehensive non-surgical treatment. Among them, 6 cases recovered from 9 to 28 d after the onset of the disease, 1 case recovered at 34 d, 1 case recovered at 56 d, and lasted from 9 to 56 days, with an average of 22.4 days. 1 case died due to a serious pulmonary infection.
Discussion
Morbidity of FDGE
Most scholars in China reported an incidence rate of 0.6%-7.0% [3] [4], while overseas reports were around 5%-10%. The incidence rate in our group was 4%.
Etiology and pathogenesis
Most scholars believe that the causes of PDGE are related to psychological factors, postoperative abdominal infection, systemic nutritional status, hypoproteinemia, electrolyte disorders, food and even drugs. In addition to the above factors, our data show that PDGE is also closely related to the surgical approach, selective vagotomy, anastomotic edema, and the site and extent of gastric resection.
The pathogenesis is currently considered to be
(1) Due to the increased gastrointestinal sympathetic nerve activity after abdominal surgery, the gastric wall releases norepinephrine or other inhibitory substances that bind directly to the α and β receptors on the cell membrane of the gastrointestinal smooth muscle, preventing the release of acetylcholine from the parasympathetic nerve in the gastrointestinal smooth muscle, thereby inhibiting the electromyographic activity of the stomach and delaying gastric emptying.
(2) Gastrectomy removes the strongest part of gastric motility, the gastric sinus and pylorus, and changes gastric motility.
(3) Reconstruction of the gastrointestinal tract affects the coordination of gastrointestinal electro-mechanical activity, resulting in retroperistalsis, especially in the Bi-II anastomosis, and the incidence of FDGE is significantly higher than that of Bi-II.
In addition, foreign data show that food delivery in the gastric cavity does not depend on the gravity of the chyme, but on the pressure difference between the gastrointestinal tract, and peristaltic dysfunction of the small intestine can increase the resistance to chyme delivery and cause muscle diastolic disorders in the gastric wall, which is the main cause of gastric retention, while simple gastrojejunal anastomosis changes the pressure difference between the gastrointestinal tract, causing disorders of gastrointestinal diastolic function and eventually causing FDGE. Six patients with perforated duodenal bulb ulcers underwent perforated ulcer repair, gastrojejunostomy, and selective vagotomy because of the large, prolonged, and heavily contaminated perforated ulcers.
In one patient, FDGE occurred several times after surgery, which was considered to be related to this factor.
(4) The postoperative stress response caused disturbances in the secretion and regulation of gastrointestinal hormones, with increased glucagon and glucagon and decreased gastrin and cholecystokinin. Under the condition of stress and intravenous nutrition, reduced insulin receptor sensitivity, relative insulin deficiency, enhanced gluconeogenesis, and increased glucagon will all cause a significant increase in blood glucose. Hyperglycemia has a significant inhibitory effect on gastric motility and is proportional to its degree of elevation.
(5) Selective vagotomy affects the recovery of gastric tone after surgery, increases the incidence of delayed gastric emptying, and reduces the ability of the stomach to store and mechanically digest food.
(6) Other factors such as psychological factors, infection, metabolism and drugs may also be involved in the occurrence of FDGE.
In conclusion, the occurrence of FDGE is the result of a combination of multiple factors and mechanisms, and understanding its etiology and mechanisms is the key to the prevention and treatment of FDGE.
Diagnosis
There is no unified standard for the diagnosis of FGDE, which is mainly based on clinical manifestations, gastrography and gastroscopy. We refer to Qin Xinyu’s diagnostic criteria for gastroparesis [10] and formulate the following diagnostic basis in combination with the actual situation of our patients.
(1) Any patient whose intestinal function has been restored after partial gastrectomy, who has gastric retention again after eating and needs gastrointestinal decompression, or who still needs gastrointestinal decompression 7 d after surgery and whose 24-hour gastric fluid volume exceeds 1000 ml;
(2) X-ray gastric iodine hydrography confirmed no gastric peristalsis and combined with gastroscopy to exclude mechanical obstruction of the anastomosis;
(3) No significant water and electrolyte disturbance and acid-base imbalance;
(4) No underlying diseases causing gastric emptying disorders, such as diabetes mellitus, connective tissue disease, etc.
We generally choose 30% pantothenic glucosamine as the contrast agent, because this contrast agent can not only understand the anastomosis, observe the gastric peristalsis and exclude the output segment jejunal obstruction, but also can be easily sucked out of the body by the gastrointestinal decompression tube after the contrast. For gastroscopy we advocate that it is generally performed about 2 weeks after surgery, which can further confirm the diagnosis and exclude the anastomotic mechanical obstruction, in addition to mechanical stimulation of the stomach.
In our group, all 9 cases underwent gastroscopy while nasal feeding tube was placed in the distal duodenum or output section of jejunum. 2 cases showed significant relief of symptoms and significant reduction of gastrointestinal drainage fluid after the examination, one of which returned to normal on the day of gastroscopy, and the other case recovered gastric function after 2 days.
Treatment
General treatment
Strict fasting, continuous gastrointestinal decompression, maintenance of water and electrolyte balance, appropriate use of corticosteroids and warm saline gastric lavage, adequate rest for the residual stomach, reduction of anastomotic edema, and application of acid control agents to reduce gastric acid secretion. In addition, it is very important to explain to patients and obtain their cooperation, because the treatment time of FDGE is often long, otherwise it will bring great difficulties to the treatment.
Nutritional support
We use three-liter bags of total intravenous nutrition solution to support FDGE patients with adequate calories, proteins, vitamins and trace elements, correct negative nitrogen balance, and intermittent blood and plasma transfusion. For patients who did not recover after more than 2 weeks, a nasal nutrition tube was placed via gastroscopy in the output section of the jejunum or the distal duodenum for enteral nutrition, with a daily drip of fluid or Regal (an enteral nutrition preparation designed specifically for hypermetabolic patients).
We believe that the advantages of enteral nutrition therapy in this group of 7 cases are not only to provide nutritional support, but also to promote intestinal peristalsis, improve intestinal mucosal function and reduce enterogenic infections.
Gastrointestinal motility drugs
Most of the gastrointestinal motility drugs used in FDGE patients can promote the recovery of gastric motility. We have used erythromycin and gastroflucan. Erythromycin is a macrolide antibiotic, which has similar effect with gastrodin and can cause strong contraction of MMC phase III to promote gastric emptying, because erythromycin can bind with gastrodin receptor to accelerate gastric emptying by simulating the muscle contraction effect of gastrodin.
In this group, erythromycin was used in 6 patients, and the effect was obvious in 4 cases and not obvious in 2 cases after 7 d of application. Gastrofacial: It has the effect of antiemetic and gastrointestinal motility, but long-term use of this drug can cause extrapyramidal side effects. We generally stop using it for about 1 week, 10mg/d, 2-3 times by intravenous infusion, and no obvious side effects were observed, and 2 out of 9 patients had obvious effects after using it.
Gastroscopic treatment
In patients with FDGE, gastroscopy can not only understand the anastomosis situation and exclude mechanical obstruction, but also put nasal nutrition tube into the distal duodenum or jejunal output section for enteral nutrition through gastroscopy, and stimulate or inject gas to promote peristaltic function recovery through gastroscopy.
In this group of patients, this method was successfully used, and two of them showed significant relief of symptoms and reduction of gastrointestinal drainage after examination, one of them returned to normal on the day of gastroscopy, and the other one recovered gastric function after two days, which may be related to mechanical stimulation of gastrointestinal smooth muscle by gastroscopy and local increase of proximal pressure to stimulate the formation of effective peristalsis.
Surgical treatment
The reoperative management of FDGE is not advocated at present. In our group, 9 patients with FDGE were cured after non-surgical comprehensive treatment, except for 1 case who died of pulmonary complications, indicating that non-surgical comprehensive treatment is effective.