Negative Feedback Mechanism of Entero-gastric Inhibitory in Delayed Gastric Emptying Following Surgery for Stomach Cancer
-
摘要:
术后胃排空延迟（DGE）是上消化道外科手术的一种常见并发症，尤其好发于远端胃切除和胰十二指肠切除手术（Whipple手术）后，其形成机制迄今不明，进一步明确其机制有助于该并发症的预防与处理。十二指肠的机械性扩张会反馈性地抑制胃排空。我们推测这一负反馈机制在近段空肠也存在，在空肠胀满或肠壁受到牵扯的情况下会导致胃排空抑制。激活这一负反馈抑制效应的外科因素众多，当用直径比较大的管形吻合器做空肠吻合时，吻合器的插入会使空肠黏膜发生环周蹭擦损伤，形成局部炎性反应。用吻合器做肠肠吻合会使输入襻形成扭转导致十二指肠和空肠扩张。此外，胃肠吻合口有可能存在轻微的张力，尤其在实施结肠前胃肠吻合时。肠黏膜的炎性水肿会造成空肠扩张，肠襻扭转会影响其通畅性，胃肠吻合口的张力会对空肠壁形成牵扯，这些因素都可能通过负反馈机制导致DGE。
Abstract:Delayed gastric emptying (DGE) is a common complication following upper gastrointestinal surgery, especially following distal gastrectomy and partial pancreaticoduodenectomy (Whipple procedure). Its underlying mechanism remains unclear and needs to be elucidated. Through negative feedback mechanisms, duodenal distension inhibits gastric emptying. In our experience in performing a gastrojejunostomy, we speculate that this mechanism may still exist in the proximal jejunum and is activated by jejunal distension or stretching. There are many surgical factors leading to this mechanism activation. When a jejunal anastomosis is created by a relative large caliber of a circular stapling device, the mucosa may suffer from a circumferential scratch or bruising injury resulting in local inflammation. Afferent loop twisting may also lead to distal duodenum and/or jejunal distension. In addition, a mild/slight tension may exist on the mesenteric side of the gastrojejuostomy, especially when the antecolic route for reconstruction of the gastrojejunostomy has been performed. The inflammatory mucosa may keep the jejunum circumferentially distended, the bowel twist might compromise the lumen patency, and tension on gastrojejuostomy would stretch the jejunal wall. Any of these factors might contribute to the mechanisms of DGE by the negative feedback mechanisms.
-
Competing interests:The author declares that he has no competing interests.
-
![]()
![]()
图 2 管形吻合器所致空肠扭转机制示意图
Figure 2 Mechanism of twisting of the afferent loop caused by circular stapler
-
[1] Macutkiewicz C. Delayed gastric emptying after pancreatic surgery[M]//Søreide K, Stättner S. Textbook of Pancreatic Cancer, Switzerland: Springer Nature. 2021: 1069-1078.
[2] Johnson LR. Gastrointestinal Physiology[M]. 9th Edition. Philadelphia: Elsevier, 2019: 31-35.
[3] Trowers E, Tischler M. Brain-gut axis and regional gastrointestinal tract motility[M]//Trowers E, Tischler M. Gastrointestinal physiology: a clinical approach. Switzerland: Springer International Publishing, 2014: 41-42.
[4] Hasler W. Gastroparesis: Pathogenesis, Diagnosis, and Management[J]. Nat Rev Gastroenterol, 2011, 8(8): 438-453. doi: 10.1038/nrgastro.2011.116
[5] Bar-Natan M, Larson GM, Stephens G, et al. Delayed gastric emptying after gastric surgery[J]. Am J Surg, 1996, 172(1): 24-28. doi: 10.1016/S0002-9610(96)00048-7
[6] Wente MN, Bassi C, Dervenis C, et al. Delayed gastric emptying (DGE) after pancreatic surgery: a suggested definition by the International Study Group of Pancreatic Surgery (ISGPS)[J]. Surgery, 2007, 142(5): 761-768. doi: 10.1016/j.surg.2007.05.005
[7] Kim SH, Keum B, Choi HS, et al. Self-expandable metal stents in patients with postoperative delayed gastric emptying after distal gastrectomy[J]. World J Gastroenterol, 2018, 24(40): 4578-4585. doi: 10.3748/wjg.v24.i40.4578
[8] Cakir M, Akinci M, Akturk OM. Delayed gastric emptying as a complication of Whipple's procedure: could it be much less frequent than anticipated? could the definition be revised? Asingle center experience[J]. Medeni Med J, 2020, 35(3): 181-187.
[9] Hayama S, Senmaru N, Hirano S. Delayed gastric emptying after pancreatoduodenectomy: comparison between invaginated pancreatogastrostomy and pancreatojejunostomy[J]. BMC Surg, 2020, 20(1): 60-65. doi: 10.1186/s12893-020-00707-w
[10] Schrempf MC, Pinto DRM, Gutschon J, et al. Intraoperative endoluminal pyloromyotomy as a novel approach to reduce delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy-a retrospective study[J]. Langenbecks Arch Surg, 2020, 406(4): 1103-1110.
[11] Tang WH, Shi X, Fan X, et al. Fullness or distension of proximal jejunum: A risk factor contributing to the delayed gastric emptying[J]. Am Surg, 2018, 84(6): e185-e187. doi: 10.1177/000313481808400604
[12] Gan T, Evers BM. Small Intestine[M]//Townsend CM, Beauchamp RD, Evers BM, et al. Sabiston textbook of surgery: the biological basis of modern surgical practice. 21th ed. St. Louis: Elsevier Inc, 2022: 1252-1253.
[13] Treacy PJ, Jamieson GG, Dent J. The effect of duodenal distension upon antropyloric motility and liquid gastric emptying in pigs[J]. Aust N Z J Surg, 1996, 66(1): 37-40. doi: 10.1111/j.1445-2197.1996.tb00698.x
[14] Hirayama N, Gunji Y, Miyazaki S, et al. Inhibitory remnant stomach motility by duodenal distention after B-I gastrectomy[J]. Hepatogastroenterology, 2005, 52(62): 633-638.
[15] Xu J, Chen JDZ. Intestinal electrical stimulation improves delayed gastric emptying and vomiting induced by duodenal distension in dogs[J]. Neurogastroenterol Motil, 2008, 20(3): 236-342.
[16] Tang WH, Fan X, Rui ZD, et al. Intestinal obstruction from end-to-side or side-to-side anastomosis made by a circular stapling device[J]. Am Surg, 2011, 77(5): 651-653. doi: 10.1177/000313481107700531
下载:
计量
- 文章访问数: 2249
- HTML全文浏览量: 606
- PDF下载量: 553
