[Effect of shenhuang ointment in promoting the rehabilitation of postoperative gastrointestinal dysfunction patients of Qi stagnation blood stasis syndrome: a clinical observation].

OBJECTIVE: To observe the effect and safety of plastering Chinese Compound Shenhuang Ointment (CSO) at Shenque (RN8) in promoting the rehabilitation of postoperative gastrointestinal dysfunction patients of qi stagnation blood stasis syndrome (QSBSS). METHODS: A prospective, multi-centered, randomized, double-blinded, controlled trial was conducted in 220 postoperative gastrointestinal dysfunction patients of QSBSS. They were randomly assigned to two groups, the CSO group (110 cases) and the placebo group (110 cases). CSO was plastered at Shenque (RN8) for 5 days after operation. The time of exhaustion, defecation, the recovery of intestinal peristalsis, integrals of TCM syndrome, and serum levels of motilin (MOT)and somatostatin (SS) were observed. RESULTS: Compared with the placebo group, the condition of exhaustion and defecation, the recovery of intestinal peristalsis on the 3rd day after operation was all improved (P < 0.05). The integrals of TCM syndrome at day 2, 3, and 4 were more significantly lowered in the CSO group than in the placebo group (P < 0.01, P < 0.05). The total effective rate of TCM syndrome was 95.3% in the CSO group, better than that in the placebo group (91.8%, P < 0.05). Compared with the placebo group, the serum MOT level increased and the serum SS level decreased at day 5 after operation in the CSO group (P < 0.05). CONCLUSIONS: The plastering of CSO at Shenque (RN8) could advance the time of exhaustion and defecation, and improve patients' clinical symptoms. And patients could tolerate well.

[The application of uncut Roux-en-Y esophagojejunostomy with distal jejunal pouch on behalf of the stomach surgery in the digestive tract reconstruction after total gastrectomy].

OBJECTIVE: To study the clinical value of uncut Roux-en-Y esophagojejunostomy with distal jejunal pouch on behalf of the stomach (URYAJP) surgery in the digestive tract reconstruction after total gastrectomy. METHODS: A retrospective analysis of radical resection of the whole stomach in 486 cases of gastric cancer patients, divided into the URYAJP group (n = 189), the P-loop Roux-en-Y behalf of the stomach surgery (PRY) group (n = 150) and pure Roux-en-Y reconstruction (RY) group (n = 147). Three groups were compared in patients with surgical reconstruction time, the occurrence of postoperative complications, the postoperative weight after 6, 12 and 24 months, the single meal food intake and prognostic nutritional index (PNI) and Visick points class situation after 12 and 24 months. RESULTS: (1) The URYAJP group and RY group had no significant difference in digestive tract reconstruction time ((37 ± 6) minutes and (38 ± 6) minutes respectively), but PRY group was significantly prolonged ((47 ± 6) minutes, t = 7.52 and 6.54, P < 0.05). (2) In the comparison of the incidence of complications, URYAJP group has 2.1% rate of Roux stay syndrome (RSS) incidence, significantly less than PRY group (21.3%) and RY group (19.7%) (χ² = 14.84, P < 0.05). (3) In the comparison the postoperative nutritional status, URYAJP group clear asset, showing the degree of ((3.1 ± 1.0) kg) weight loss after 12 months (t = 25.03 and 22.99, P < 0.05). And after 12, 24 months, a single meal eating reached the preoperative level is 94.8% and 96.9% in URYAJP group, while PRY group and RY group is less than 50% (χ(2) = 61.10, 69.17, 65.17 and 73.29, P < 0.05). URYAJP Group reach the preoperative levels of PNI in 24 months after surgery, while PRY and RY group were still lower than per-operation (t = 106.97 and 100.37, P < 0.05). (4) The Visick points class I-II postoperative 12 and 24 months in URYAJP group were 92.7% and 93.8%, significantly better than group B and C (χ² = 10.63, 14.19, 10.10 and 10.74, P < 0.05). CONCLUSIONS: URYAJP surgery give full play to maintain intestinal continuity, simple operation, and advantages of food storage bags, it can reduce the long-term postoperative complications, improve the nutritional status of patients and improve quality of life. It is worthy of promoting a way of gastrointestinal reconstruction.

Expression of TRAF6 and ubiquitin mRNA in skeletal muscle of gastric cancer patients.

OBJECTIVE: To investigate the prognostic significance of tumor necrosis factor receptor (TNFR),-associated factor 6 (TRAF6),-and ubiquitin in gastric cancer patients. METHODS: Biopsies of the rectus abdominis muscle were obtained intra operatively from 102 gastric cancer patients and 29 subjects undergoing surgery for benign abdominal diseases, and muscle TRAF6 and ubiquitin mRNA expression and proteasome proteolytic activities were assessed. RESULTS: TRAF6 was significantly upregulated in muscle of gastric cancer compared with the control muscles. TRAF6 was upregulated in 67.65% (69/102) muscle of gastric cancer. Over expression of TRAF6 in muscles of gastric cancer were associated with TNM stage, level of serum albumin and percent of weight loss. Ubiquitin was significantly upregulated in muscle of gastric cancer compared with the control muscles. Ubiquitin was upregulated in 58.82% (60/102) muscles of gastric cancer. Over expression of ubiquitin in muscles of gastric cancer were associated with TNM (Tumor-Node-Metastasis) stage and weight loss. There was significant relation between TRAF6 and ubiquitin expression. CONCLUSIONS: We found a positive correlation between TRAF6 and ubiquitin expression, suggesting that TRAF6 may up regulates ubiquitin activity in cancer cachexia. While more investigations are required to understand its mechanisms of TRAF6 and ubiquitin in skeletal muscle. Correct the catabolic-anabolic imbalance is essential for the effective treatment of cancer cachexia.

Beneficial effects of continual jejunal interposition after subtotal gastrectomy.

BACKGROUND: The ideal post-gastrectomy reconstruction procedure should maintain the normal digestive function and restore intestinal transit to improve the patient quality of life. The aim of this study was to evaluate the effects of integral continual jejunal interposition after subtotal gastrectomy on the nutritional status, glucose levels, and gastric-intestinal motility. METHODS: The study investigated the effects of the integral continual jejunal interposition, the Billroth I and Billroth II operations, and the isolated jejunal interposition following subtotal distal gastrectomy on the blood glucose, insulin, routine blood parameters, liver function, and myoelectrical activity in Beagle dogs. RESULTS: The weights of the dogs decreased during the first post-operative weeks. Dogs in the integral continual jejunal interposition, Billroth I, and Billroth II groups gained significantly more weight by 8 weeks. The prognosis nutrition index of the dogs decreased in the first 2 post-operative weeks and increased significantly by 4 weeks in the integral continual jejunal interposition and Billroth I groups. The group with duodenal exclusion (Billroth II) had significantly higher glucose levels compared to the normal control group. The insulin curve was much higher in dogs that underwent the Billroth I, continual jejunal interposition, and isolated jejunal interposition than the Billroth II and normal groups. The frequencies of fasting and postprandial jejunal pacesetter potentials (PPs) were greater in the continual jejunal interposition and Billroth I groups than that in the isolated jejunal interposition and Billroth II groups. The percentage of aboral propagation of PPs was greater in the continual jejunal interposition group than the Billroth I, isolated jejunal interposition, and Billroth II groups. CONCLUSION: Continual jejunal interposition after subtotal gastrectomy avoids jejunal transection, maintains the duodenal passage and food storage bags, and reduces the influence of blood glucose and insulin.

The effect of continuous jejunal interposition on gastrointestinal hormones after distal gastrectomy.

The objective of our study was to determine the effect of continuous jejunal interposition on gastrointestinal hormones after distal gastrectomy, and lay a foundation for surgical management.Distal subtotal gastrectomy experimental model were established on 24 adult Beagle dogs. Digestive tract reconstruction of the dogs was randomly divided into continuous jejunal interposition group, Billroth II anastomosis group and isolated jejunum interposition group. The content of serum gastrin, plasma motilin and cholecystokinin after different digestive tract reconstructions was detected and compared by enzyme-linked immunosorbent assay. In the dogs which received continuous jejunal interposition, postoperative serum gastrin level was significantly lower than before surgery either in fasting or postprandial state (all p<0.05). The serum gastrin level of continuous jejunal interposition group was significantly higher than the other groups in postprandial state (all p<0.05), and was significantly higher than Billroth II -type anastomosis group in fasting state (p<0.05). Furthermore, the postoperative plasma motilin and cholecystokinin levels were significantly higher than before surgery either in fasting or postprandial in dogs received continuous jejunal interposition (all p<0.05). The postoperative plasma motilin level of continuous jejunal interposition group was significantly higher than the other groups in postprandial state (all p<0.05), and was significantly higher than Billroth II -type anastomosis group in fasting state (p<0.05). However, the postoperative cholecystokinin level of continuous jejunal interposition group was significantly lower than the other groups (all p <0.05).Continuous jejunal interposition after distal gastrectomy could maintain the postoperative plasma motilin and serum gastrin in a relatively high level, while cholecystokinin in a low level.

[Laparoscopic versus open wedge resection for gastrointestinal stromal tumors of the stomach: a clinical controlled study].

OBJECTIVE: To compare the surgical outcomes between laparoscopic and open wedge resection for gastrointestinal stromal tumors of the stomach. METHODS: Clinical data of 18 cases undergoing laparoscopic wedge resection from June 2000 to August 2009 at the Zhejiang Provincial People's Hospital were compared with 30 patients treated by open surgery. The perioperative parameters and prognosis data of the two groups were compared. RESULTS: Compared to the open group, laparoscopic group was found with longer operative time, less blood loss, less requirement of postoperative analgesia, earlier resumption of oral intake, earlier return of first flatus, and shorter postoperative hospital stay(all P<0.05). There were no postoperative deaths in both groups. Postoperative complication rate was significantly lower in the laparoscopic group(5.5% vs. 33.3%, P<0.05). The postoperative recurrence rates were 11.8%(2/17) and 10.7%(3/28); the 5-year survival rates were 78% and 63%, respectively, and the difference was not statistically significant(P>0.05). CONCLUSION: Laparoscopic wedge resection is a feasible treatment option for GISTs of the stomach.

[Effect of early enteral nutrition supplemented with glutamine on postoperative intestinal mucosal barrier function in patients with gastric carcinoma].

OBJECTIVE: To investigate the effect of early enteral nutrition (EEN) supplemented with glutamine on postoperative intestinal mucosal barrier function of patients with gastric carcinoma. METHODS: Eighty patients with gastric carcinoma who underwent intraoperative peritoneal hyperthermic chemotherapy(IPHC) were randomized into two groups: EEN+glutamine (EEN+Gln) group(n=40) and EEN group(n=40). Intestinal mucosal barrier function was evaluated by serum diamine oxidase (DAO), ratio of lactulose to mannitol(L/M), endotoxin lipopolysaccharides(LPS), and tumor necrosis factor-α(TNF-α) at 1 day before operation, 1 day, 7 days, 12 days after operation. Time to first flatus and tolerance to EEN were recorded as well. RESULTS: There were no significant differences in the two groups in demographics(all P>0.05). Two cases(5%) in the EEN+Gln group and 1 case (2.5%) in the EEN group could not tolerate well(P>0.05). On postoperative day 1, there were no differences in serum DAO, L/M ratio, LPS, TNF-α between the two groups (P>0.05). On postoperative day 7, all the parameters for mucosal barrier function were significantly lower in the EEN+Gln group. On postoperative day 12, the urinary L/M and DAO, LPS, and TNF-α were still significantly lower in the EEN+Gln group, however, urinary L/M was comparable between the two groups. There were no differences between the two groups in the time to first flatus (P>0.05). CONCLUSION: The immunologic tolerance of enteral nutrition supplemented with glutamine is favorable, which provides protective effect on intestinal mucosal barrier in patients with gastric carcinoma undergoing IPHC.

[Oral glucose tolerance test and insulin response in Beagle dogs after subtotal distal gastrectomy].

OBJECTIVE: To evaluate the impact of reconstruction techniques after subtotal gastrectomy on postoperative glucose and insulin levels after oral glucose tolerance test (OGTT). METHODS: Distal gastrectomy was performed in 38 Beagle dogs. Reconstruction techniques used included integral continual jejunal interposition (n=9), Billroth I( (n=6), Billroth II( (n=7), and isolated jejunal interposition (n=8). Eight controls were used. OGTT was conducted to examine the changes in glucose and insulin levels. RESULTS: Compared to controls, glucose significantly increased in all the 4 operative groups and peaked at 60 min. Billroth II( was associated with the most significant increase. Insulin level significantly increased in all the experimental groups in response to food stimulus and peaked at 60 min. However, the increase of insulin in Billroth II( group was not as prominent as in other groups. CONCLUSIONS: Fluctuation of blood glucose after gastrectomy may be mitigated and insulin elevated if duodenal passage is preserved. Continual jejunal interposition should be given priority when Billroth I( reconstruction is not feasible.

[Experimental research of integral continuous jejunal interposition after subtotal distal gastrectomy].

OBJECTIVE: To evaluate nutritional status, myoelectrical activity, and gastrointestinal tract emptying capacity after integral continuous jejunal interposition following subtotal gastrectomy. METHODS: According to different re-construction techniques, 30 Beagle dogs were divided into four groups after subtotal distal gastrectomy: group 1(n=9, integral continuous jejunal interposition), group 2(n=6, Billroth I(), group 3(n=7, Billroth II(), group 4(n=8, isolated jejunal interposition). Blood cell counts, liver function, myoelectrical activity and the rate of gastrointestinal tract emptying were compared among the four groups. RESULTS: At week 12 after operation, the body weight in group 1 [(9.65±1.54) kg] was significantly higher than that in group 2[(9.25±1.76)kg], group 3[(9.31±1.54)kg] and group 4[(7.77±1.46)kg]. At week 4, the prognostic nutritional index in group 1(2671.9±49.9) was significantly higher than that in group 3(2555.9±54.7) and group 4(2440.9±54.3), but similar to that in group 2(2791.8±54.3). At week 6, the fasting and postprandial frequency of jejunal pacesetter potentials in group 1 were higher than those in group 3 and group 4(P<0.05) but comparable with those in group 2. The emptying rate of food in the four groups were 95.4%, 91.3%, 93.1% and 94.2%, respectively and there were no significant differences(P>0.05). However, as compared with group 2 and group 3, group 1 had longer operative time and later regular diet resumption, more severe abdominal adhesion(P<0.05). CONCLUSION: Continuous jejunal interposition should be considered when Billroth I( is not feasible after subtotal gastrectomy.

[Different procedures of alimentary tract reconstruction after subtotal distal gastrectomy in dogs].

OBJECTIVE: To explore an ideal procedure of alimentary tract reconstructions after subtotal distal gastrectomy. METHODS: Thirty-two healthy adult beagle dogs were randomly divided into experimental groups A, B, C and control group (n=8). Groups A, B, C operated by subtotal distal gastrectomy underwent 3 different reconstruction methods: continual jejunal interposition (CJI), Billroth II and Roux-en-Y. The control group received a sham operation. Dogs were observed for 12 weeks post-operation. The different parameters of body weight, food intake, PNI (prognostic nutritional index) and peripheral blood concentration of ghrelin were measured in 4 groups. RESULTS: The body weight, food intake and PNI in Groups A, B, C decreased significantly at post-operation versus pre-operation. There was a slow elevation of body weight, food intake and PNI at Week 12. Group A was significantly better than Groups B and C (P<0.05) while there was no significant difference between Groups B and C. The plasma ghrelin concentrations in Groups A, B, C were significantly reduced at Day 1 post-operation versus pre-operation. But no difference was observed among Groups A, B and C. However an elevated ghrelin concentration was observed at Week 1 post-operation. At Week 12 post-operation, the plasma ghrelin concentration in Group A increased significantly versus Groups B and C (both P<0.05). However, the plasma ghrelin concentration, food intake and PNI were not significantly changed in control group (P>0.05). CONCLUSIONS: The CJI reconstruction procedure is ideally suited for the preservation of duodenal passage after subtotal distal gastrectomy. Subsequently it leads to a significant elevation of circulating ghrelin concentration and a rapid post-operative recovery of food intake, body weight and PNI.

[Nutritional therapy of duodenocutaneous fistula].

OBJECTIVE: To summarize the experience in nutritional support for the management of duodenocutaneous fistula. METHODS: Data of 32 patients with duodenocutaneous fistula in Zhejiang provincial people's hospital from January 1999 to December 2009 were analyzed retrospectively. RESULTS: The mean duration of nutritional support was 35.6 days (range, 8-82 days). Eight received total parenteral nutrition, 2 total enteral nutrition, and 22 parenteral nutrition combined with enteral nutrition respectively. Succus entericus reinfusion with enteral nutrition was used in 11 cases, glutamine-enriched nutritional support in 28 cases, somatostatin in 12 cases. In these patients, the healing rate was 75.0% after conservative treatment. In the 8 patients who underwent surgery, 6 were cured and 2 died (due to severe abdominal infection and multiple organ failure). A total of 30 patients had the fistulas cured and discharged. CONCLUSIONS: Parenteral nutrition combined with enteral nutrition, succus entericus reinfusion combined with enteral nutrition, glutamine-enriched nutritional support and somatostatin are important factors for the healing of duodenocutaneous fistulas.

[Clinical study on the alimentary canal reconstruction of uncutted Roux-en-Y with jejunal pouch for total gastrectomy].

OBJECTIVE: To investigate the efficacy of uncutted Roux-en-Y esophagojejunostomy with jejunal pouch (URYJP) after total gastrectomy. METHODS: Total gastrectomy was performed on 168 patients of gastric cancer, and 3 methods were used for reconstruction: the uncutted Roux-en-Y esophagojejunostomy with a jejunal pouch was performed on 69 patients(group A),Roux-en-Y esophagojejunostomy with the P-type jejunal pouch on 50 patients(group B),and Roux-en-Y esophagojejunostomy with the Orr-type jejunal pouch on 49 patients (group C). The alimentary tract reconstruction time, morbidity and mortality were compared. The 121 cases that survived for more than 1 year were analyzed for quality of life(QOL),including body weight, intake quantity, prognosis nutritional index (PNI), and Visick scores 6 and 12 months after the operations. RESULTS: All the patients recovered quickly and no anastomosis leakage or duodenal fistulas were found. It took (30+/-7) minutes to finish the reconstruction in group A, which was significantly shorter than that in group B [(57+/-6) minutes] or in group C [(48+/-6) minutes]. There were no significant differences among 3 groups in the incidence of alkaline reflux gastritis. The incidence of Roux stasis syndrome was 2.2% in group A, which was significantly lower than 17.9% and 19.4% in group B and C. Weight loss and food intake gain in group A was superior to those in group B and C 6 months and 12 months postoperatively. As compared with prognosis nutritional index(PNI) postoperatively, those of 3 groups decreased significantly 6 months postoperatively. At 12 months after operation, the PNI of group A returned to the level before operation, while PNI of both group B and C remained significantly lower than those before operation (both P < 0.05). The Visick score of group A was superior to those of group B and C 6 months and 12 months postoperatively. CONCLUSIONS: The new uncutted Roux operation with jejunal pouch can prevent alkaline reflux gastritis and Roux-en-Y stasis syndrome. It may be a standard procedure for reconstruction after total gastrectomy.

[Expression of vascular endothelial growth factor C and survivin in gastric carcinoma and their clinical implications].

OBJECTIVE: To investigate the expression of vascular endothelial growth factor C (VEGF-C) and survivin protein in human gastric carcinoma,and to evaluate their clinical implications. METHODS: The expressions of VEGF-C and survivin protein in tumor tissues,matched para- tumor tissues from 97 cases with gastric cancer and normal tissues form 20 normal controls,were determined by immunohistochemistry. Their relationships with clinicopathological parameters were analyzed. RESULTS: The positive rate of VEGF-C and survivin protein in tumor tissues (66.0% and 57.2%) was significantly higher than those in matched para-tumor tissues normal tissues (P< 0.05). There were no significant differences in VEGF-C expression considering tumor size,localization,histological grade,venous invasion,and distant metastasis (P > 0.05), while its expression was correlated with serosal infiltration, lymphatic invasion, lymph node metastasis and TNM stage III-IV (P< 0.05). The survivin expression was significantly related with serosal infiltration,lymphatic invasion, regional lymph node metastasis,distant metastasis, and TNM stage III- IV (P< 0.05), but not with histological grade, localization,venous invasion,and tumor size (P > 0.05). The 1, 3 and 5-year survival rates of the patients with positive VEGF-C or survivin protein were significantly lower than those of the patients with negative VEGF-C or survivin (P< 0.05), respectively. In additional,the expression of VEGF-C was positively correlated with survivin expression in gastric carcinoma (P< 0.01). CONCLUSION: The expressions of VEGF-C and/or survivin may be indicators for poor prognosis of gastric carcinoma.