Liquid-containing Refluxes and Acid Refluxes May Be Less Frequent in the Japanese Population Than in Other Populations: Normal Values of 24-hour Esophageal Impedance and pH Monitoring

BACKGROUND/AIMS: Twenty-four-hour esophageal impedance and pH monitoring allows detection of all types of reflux episodes and is considered the best technique for identifying gastroesophageal refluxes. However, normative data for the Japanese population are lacking. This multicenter study aimed to establish the normal range of 24-hour esophageal impedance and pH data both in the distal and the proximal esophagus in Japanese subjects. METHODS: Forty-two healthy volunteers (25 men and 17 women) with a mean ± standard deviation age of 33.3 ± 12.4 years (range: 22–72 years) underwent a combined 24-hour esophageal impedance and pH monitoring. According to the physical and pH properties, distal or proximal esophageal reflux events were categorized. RESULTS: Median 45 reflux events occurred in 24 hours, and the 95th percentile was 85 events. Unlike previous reports, liquid-containing reflux events are median 25/24 hours with the 95th percentile of 62/24 hours. Acidic reflux events were median 11/24 hours with the 95th percentile of 39/24 hours. Non-acidic gas reflux events were median 15/24 hours with the 95th percentile of 39/24 hours. Proximal reflux events accounted for 80% of the total reflux events and were mainly non-acidic gas refluxes. About 19% of liquid and mixed refluxes reached the proximal esophagus. CONCLUSIONS: Unlike previous studies, liquid-containing and acidic reflux events may be less frequent in the Japanese population. Non-acidic gas reflux events may be frequent and a cause of frequent proximal reflux events. This study provides important normative data for 24-hour impedance and pH monitoring in both the distal and the proximal esophagus in the Japanese population.

18-3Early effect of carbonated water administration on liquid gastric emptying: crossover study using the ¹³C breath test / 日本温泉気候物理医学会雑誌

<b>Background and Aims: </b>The gastrointestinal motility effects by carbonated water have not yet been sufficiently investigated. The aim of this study was to determine whether single pre-prandial carbonated water administration might have an effect on the rate of liquid gastric emptying using the ¹³C-acetic acid breath test.<BR><b>Methods:</b> Eight healthy volunteers (F/M; 3/5) participated in this randomized, 3-way crossover study. The subjects fasted overnight and were randomly assigned to receive 200mL of carbonated water before ingestion of the liquid test meal (200 kcal per 200 mL, containing 100 mg ¹³C acetate) or 200mL of carbonated water before the test meal or the test meal alone. Under all conditions, breath samples were collected for 150 min following the meal. Liquid gastric emptying was estimated by the values of the following parameters: T_1/2, T_lag, the gastric emptying coefficient (GEC) and the regression-estimated constants (β and κ), calculated using the ¹³CO₂ breath excretion curve using the conventional formulae. The parameters between the 3 test conditions were compared statistically.<BR><b>Results: </b>Carbonated water significantly decreased k and beta, but T_1/2, T_lag and GEC remained unchanged.<BR><b>Conclusions: </b>The present study revealed that carbonated water has dual effects on liquid emptying: an initial acceleration with a subsequent deceleration in asymptomatic volunteers.

18-3 Early effect of carbonated water administration on liquid gastric emptying: crossover study using the 13C breath test / 日本温泉気候物理医学会雑誌

Background and Aims: The gastrointestinal motility effects by carbonated water have not yet been sufficiently investigated. The aim of this study was to determine whether single pre-prandial carbonated water administration might have an effect on the rate of liquid gastric emptying using the 13C-acetic acid breath test. Methods: Eight healthy volunteers (F/M; 3/5) participated in this randomized, 3-way crossover study. The subjects fasted overnight and were randomly assigned to receive 200mL of carbonated water before ingestion of the liquid test meal (200 kcal per 200 mL, containing 100 mg 13C acetate) or 200mL of carbonated water before the test meal or the test meal alone. Under all conditions, breath samples were collected for 150 min following the meal. Liquid gastric emptying was estimated by the values of the following parameters: T1/2, Tlag, the gastric emptying coefficient (GEC) and the regression-estimated constants (β and κ), calculated using the 13CO2 breath excretion curve using the conventional formulae. The parameters between the 3 test conditions were compared statistically. Results: Carbonated water significantly decreased k and beta, but T1/2, Tlag and GEC remained unchanged. Conclusions: The present study revealed that carbonated water has dual effects on liquid emptying: an initial acceleration with a subsequent deceleration in asymptomatic volunteers.

Comparative Study of 2 Different Questionnaires in Japanese Patients: The Quality of Life and Utility Evaluation Survey Technology Questionnaire (QUEST) Versus the Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease Questionnaire (FSSG)

BACKGROUND/AIMS: The aim of this study was to examine the convenience of the quality of life and utility evaluation survey technology (QUEST) questionnaire and the frequency scale for the symptoms of gastroesophageal reflux disease (FSSG) questionnaire as self-assessment diagnostic instrument. METHODS: This was a two-way crossover study conducted over 6 weeks from September 2010 to November 2010. The subjects were 60 consecutive patients admitted to the Hiratsuka city hospital with a gastrointestinal condition, regardless of the coexistence of heartburn. They were assigned to fill in both the QUEST and FSSG questionnaires in random order. We analyzed the time taken to complete the questionnaires, whether subjects asked any questions as they filled in the questionnaire, and the questionnaire scores. RESULTS: Comparison of the QUEST and the FSSG revealed significant differences in the completion time (196.5 vs. 97.5 seconds, respectively; P or = 4 was lower than < 4 (170.5 vs. 214.0 seconds, respectively; P = 0.022), and the QUEST score was significantly higher without questions than with question (3 vs. 1 points, respectively; P = 0.025). CONCLUSIONS: This study revealed that the FSSG questionnaire may be easier for Japanese subjects to complete than the QUEST questionnaire.

Early Effect of Single-dose Sitagliptin Administration on Gastric Emptying: Crossover Study Using the 13C Breath Test

BACKGROUND/AIMS: The gastrointestinal motility effects of endogenous incretin hormones enhanced by dipeptidyl peptidase-IV (DPP-IV) inhibitors have not yet been sufficiently investigated. The aim of this study was to determine whether single pre-prandial sitagliptin, the DPP-IV inhibitor, administration might have an effect on the rate of liquid gastric emptying using the 13C-acetic acid breath test. METHODS: Ten healthy male volunteers participated in this randomized, two-way crossover study. The subjects fasted for overnight and were randomly assigned to receive 50 mg sitagliptin 2 hours before ingestion of the liquid test meal (200 kcal per 200 mL, containing 100 mg 13C-acetate) or the test meal alone. Under both conditions, breath samples were collected for 150 minutes following the meal. Liquid gastric emptying was estimated by the values of the following parameters: the time required for 50% emptying of the labeled meal (T1/2), the analog to the scintigraphy lag time for 10% emptying of the labeled meal (Tlag), the gastric emptying coefficient and the regression-estimated constants (beta and kappa), calculated by using the 13CO2 breath excretion curve using the conventional formulae. The parameters between the 2 test conditions were compared statistically. RESULTS: No significant differences in the calculated parameters, including T1/2, Tlag, gastric emptying coefficient or beta and kappa, were observed between the 2 test conditions. CONCLUSIONS: The present study revealed that single-dose sitagliptin intake had no significant influence on the rate of liquid gastric emptying in asymptomatic volunteers.

Change of Gastric Emptying With Chewing Gum: Evaluation Using a Continuous Real-Time 13C Breath Test (BreathID System)

BACKGROUND/AIMS: There are few reports on the correlation between chewing gum and the gastrointestinal functions. But previous report showed use of chewing gum to be an effective method for controlling gastrointestinal symptoms. The aim of this study was to determine the correlation between chewing gum and gastric emptying using the continuous real time 13C breath test (BreathID system). METHODS: Ten healthy male volunteers participated in this randomized, 2-way crossover study. The subjects fasted overnight and were randomly assigned to chewing gum (Xylish, 2-3/1 tablet) for an hour following intake of a test meal (200 kcal/200 mL) or intake of the test meal alone. Gastric emptying was monitored for 4 hours after administration of the test meal by the 13C-acetic acid breath test performed continually using the BreathID system. RESULTS: No significant differences in the calculated parameters, namely, T1/2 (median, 111.82 vs 109.26 minutes; P = 0.575), Tlag (median, 53.28 vs 56.53 minutes; P = 0.333), gastric emptying coefficient (median, 3.58 vs 3.65; P = 0.285), regression-estimated constant beta (median, 1.85 vs 1.80; P = 0.575) and regression-estimated constant kappa (median, 0.61 vs 0.62; P = 0.959) were observed between the test meal alone group and the test meal and chewing gum group. CONCLUSIONS: This study showed that chewing gum had no effect on the rate of gastric emptying. Therefore, since chewing gum did not enhance the speed of gastric emptying, it may ameliorate gastrointestinal symptoms through other mechanisms, such as saliva and autonomic nervous system.

Mosapride Accelerates the Delayed Gastric Emptying of High-Viscosity Liquids: A Crossover Study Using Continuous Real-Time 13C Breath Test (BreathID System)

BACKGROUND/AIMS: The administration of liquid nutrients to patients is often accompanied by complications such as gastroesophageal reflux. To prevent gastroesophageal reflux, high-viscosity liquid meals are used widely, however, it still remains controversial whether high-viscosity liquid meals have any effect on the rate of gastric emptying. The present study was conducted with the aim of determining whether high-viscosity liquid meals had any effect on the rate of gastric emptying and mosapride might accelerate the rate of gastric emptying of high-viscosity liquid meals. METHODS: Six healthy male volunteers underwent 3 tests at intervals of > 1 week. After fasting for > 8 hours, each subject received one of three test meals (liquid meal only, high-viscosity liquid meal [liquid meal plus pectin] only, or high-viscosity liquid meal 30 minutes after intake of mosapride). A 13C-acetic acid breath test was performed, which monitored the rate of gastric emptying for 4 hours. Using the Oridion Research Software (beta version), breath test parameters were calculated. The study parameters were examined for all the 3 test conditions and compared using the Freidman test. RESULTS: Gastric emptying was significantly delayed following intake of a high-viscosity liquid meal alone as compared with a liquid meal alone; however, intake of mosapride prior to a high-viscosity liquid meal was associated with a significantly accelerated rate of gastric emptying as compared with a high-viscosity liquid meal alone. CONCLUSIONS: This study showed that high-viscosity liquid meals delayed gastric emptying: however, mosapride recovered the delayed rate of gastric emptying by high-viscosity liquid meals.

Effects of Histamine-2 Receptor Antagonists and Proton Pump Inhibitors on the Rate of Gastric Emptying: A Crossover Study Using a Continuous Real-Time 13C Breath Test (BreathID System)

BACKGROUND/AIMS: The effects of Histamine-2 receptor antagonists and proton pump inhibitors on the gastrointestinal motility have not yet been sufficiently investigated. The aim of this study was to determine the effects of intravenous bolus administration of famotidine and omeprazole on the rate of gastric emptying using the continuous 13C breath test (BreathID system, Exalenz Bioscience Ltd, Israel). METHODS: Twelve healthy male volunteers participated in this randomized, 3-way crossover study. After fasting overnight, the subjects were randomly assigned to receive 20 mg of famotidine, 20 mg of omeprazole or 20 mL of saline alone by intravenous bolus injection before a test meal (200 kcal per 200 mL, containing 100 mg of 13C-acetate). Gastric emptying was monitored for 4 hours after the ingestion of test meal by the 13C-acetic acid breath test performed using the BreathID system. RESULTS: No significant differences in the calculated parameters, namely, the T1/2, Tlag, GEC, beta and kappa, were observed among the 3 test conditions. CONCLUSIONS: The study revealed that intravenous administration of gastric acid suppressant drugs had no significant influence on the rate of gastric emptying in comparison with that of saline alone as a placebo. Our results indicating the absence of any effect of either famotidine or omeprazole on accelerating the rate of gastric emptying suggest that both medications can be administered safely to patients suffering from hemorrhagic peptic ulcers who need to be kept nil by mouth from the viewpoint of possible acceleration of gastrointestinal motility in the clinical setting.

Simple and Easy Techniques for Mitral Valve Exposure with a Single Retractor / 日本心臓血管外科学会雑誌

Adequate exposure is crucial for successful mitral valve surgery. We report simple techniques for optimizing mitral valve exposure via conventional left atriotomy. The right side of the pericardium is sutured to the chest wall after medial sternotomy and pericardiotomy. We mobilize both the superior and inferior vena cava by dissecting the pericardium on their right side. Tourniquets are placed around both venae cavae and hitched up to the left after bicaval cannulation. Then the right side of the left atrium is lifted up and exposed. A longitudinal incision of the left atrium allows excellent exposure of the mitral valve using a single retractor. We adopted these procedures for 38 consecutive patients for mitral valve plasty, and additional incisions were not required. Simple mitral plasty procedure in 18 cases required 212±32 min for operation, 120±22 min for extracorporeal circulation and 88±18 min for aortic cross clamp. We conclude that this method is simple and does not lengthen the procedure.

A Case of Cleft Mitral Valve Associated with Papillary Muscle Abnormality in an Adult / 日本心臓血管外科学会雑誌

Isolated cleft of the anterior mitral leaflet in the presence of an intact atrioventricular septum is a rare cause of mitral regurgitation. We report a surgical case with cleft of the anterior mitral leaflet and abnormality of papillary muscles. A 53-year-old man was admitted to our hospital because of congestive heart failure. Echocardiography showed severe mitral regurgitation, severe tricuspid regurgitation, abnormal direct connection of the anterolateral papillary muscle and the anterior mitral leaflet and adhesion of the base of papillary muscles. At the posterior portion of the anterior leaflet, a 1-cm cleft was found during surgery. The top of the anterolateral papillary muscle adhered to the anterior leaflet, but rheumatic changes were not noted. The cleft was sutured directly, and annuloplasty was performed with a 31-mm Duran flexible ring. Tricuspid annuloplasty was also performed with the DeVega method. His postoperative course was not eventful. Mitral regurgitation caused by mitral cleft associated with abnormal connection of papillary muscles and the mitral leaflet have not been previously reported.

Successful Treatment of a Chronic Pulmonary Thromboembolism Associated with Right Atrial Thrombus, Atrial Fibrillation and Tricuspid Insufficiency / 日本心臓血管外科学会雑誌

We describe an unusual case of a chronic pulmonary thromboembolism with right atrial thrombus. A 56-year-old man suffering from chronic pulmonary thromboembolism for 5 years complained of increasing dyspnea. Computed tomography revealed massive emboli in bilateral pulmonary arteries and a thrombus in the right atrium. Massive tricuspid regurgitation and atrial fibrillation were also recognized. We performed pulmonary thromboendarterectomy using a Jamieson rigid long miniature sucker with a rounded tip and our original flexible sucker under deep hypothermic circulatory arrest. Right atrial thrombectomy, tricuspid annuloplasty and a Maze procedure were also performed during the cooling, recirculating, and warming period. His postoperative cause was uneventful, and he was able to return to an ordinary lifestyle without acquiring oxygen inhalation. Tricuspid annuloplasty and Maze operation during pulmonary thromboendarterectomy contributed to the maintenance of stable homodynamics during and after surgery.

A Case of Isolated Interruption of the Aortic Arch without Any Complications of Other Cardiovascular Malformations / 日本心臓血管外科学会雑誌

A 7-year-old boy suffered from isolated interruption of the aortic arch without any other complications or cardiovascular malformations. Cardiac murmur, which had been apparent since one month of age, had been left untreated because of the absence of any symptoms of heart failure. Isolated interruption of the aortic arch was noted during a routine physical examination at school and the patient was referred to our hospital for a complete medical evaluation. Blood-pressure difference was recognized not only between the right side and the left side of the upper extremities but also between the upper and lower extremities. On the basis of the results obtained via magnetic resonance angiography (MRA) and aortography, a definitive diagnosis of isolated interruption of the aortic arch was made. Reconstruction of the aortic arch by synthetic implant was indicated. The blood-pressure difference disappeared and the postoperative course was satisfactory.