Delayed gastric emptying in Ivor Lewis Gastro-oesophagectomy
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Delayed gastric emptying(DGE) affects 17.5% of Ivor Lewis Gastro-oesophagectomy(ILGO) patients in my unit. DGE diagnosis is varied globally due to definition subjectivity. Definition standardisation along with a diagnostic algorithm will assist clinicians in obtaining accurate diagnoses. Additionally, DGE pathophysiology is unknown and understanding it will guide treatment. 10 patients with and without DGE from our ILGO database between 1/12/2011 to 30/06/2017 had their chest X-ray and nasogastric tube(NG) algorithm from our enhance recovery protocol assessed. DGE was considered if net NG output and/or conduit size was >50% with its performance assessed. To assess treatment, those patients were divided into: patients receiving intra-operative pyloric botulinum toxin(BOTOX) injections and those without. Comparative analysis against DGE diagnosis was performed. To assess pathophysiology and a novel investigation, 65 patients from 01/12/2017 to 31/12/2019 had blood and breath sampled postoperatively with ingestion of a carbon-13 laced meal. DGE patients had repeated test after pyloric dilatation. Analyses of gut hormones(GH): glucagon-like-peptide-1(GLP-1) and peptide tyrosine tyrosine(PYY), were conducted based on DGE status and treatment. Post-operative DGE-related symptoms(PODRS) were assessed using a modified questionnaire. The algorithm had sensitivity of 100.0%, and specificity of 80.0%. 16.9% of patients with BOTOX compared to 17.8% without, had DGE, p=0.876. For GH, there were no differences in GLP-1 but PYY was raised in non-DGE patients with similar findings in post-dilatation patients. The breath test was found to be inaccurate and the symptomology scores showed no differences between DGE and non-DGE patients. Hence, the algorithm showed high diagnostic accuracy and can be used to standardise DGE definition. BOTOX did not show efficacy in treating DGE nor was the breath test an effective tool. Only PYY showed a difference in GH profile but the significance is unknown. PODRS appeared similar in all patients suggesting that DGE treatment with pyloric dilatation did not cause detriment.
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